Every finding on record at Hibriten Mountain Nursing and Rehabilitation

Based on record review and staff and Consultant Pharmacist interviews, the facility failed to have a system in place to ensure an accurate account of 1 of 1 resident's controlled medications (Resident #98), failed to have effective systems in place to ensure 2 of 2 residents (Resident #53 and Resident #74) had their physician prescribed narcotic pain medication available for administration, and the facility also failed to have a system to maintain an accurate receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled drugs for 5 of 5 months. The deficient practice occurred for 3 of 4 residents reviewed for misappropriation of medications.The findings included: Resident #98 was admitted to the facility on [DATE]. Resident #98 discharged on 01/15/26. A physician order dated 08/29/25 read; Oxycodone HCl oral tablet 30 milligrams (mg) – Give one tablet by mouth every 4 hours as needed for chronic pain. Review of the Initial Allegation Report submitted to the state agency on 12/23/25 indicated there was possible misappropriation of Resident #98's medication after noticing a discrepancy in Resident #98's oxycodone medication. Review of the Investigation Report dated 12/30/25 revealed Resident #98 was discharged from the facility to the hospital and while he was out of the facility, two doses of Resident #98's 30 milligram(mg) Oxycodone (a opioid pain medication) was signed out as being given to Resident #98. The facility's investigation found that one of the oxycodone tablets was signed out by Nurse #4 but were unable to determine who signed out the 2nd oxycodone tablet. Nurse #4 was reportedly uncooperative with the investigation and was terminated and the facility reported Nurse #4 to the Board of Nursing. Per the facility's report, due to Nurse #4's lack of cooperation and being unable to determine the 2nd signature, they could not unsubstantiate or substantiate the allegation. Review of Resident #98's progress notes in his electronic health record revealed a note dated 12/17/25 that read: [Patient] is unresponsive and hypotensive and hypoxic. [Emergency Medical Services] called. Patient's [family] notified. The note was time-stamped 5:40 PM and was written by Nurse #4. Additional review of Resident #98's progress notes revealed a note dated 12/17/25 at 8:33 PM that was a medication administration note for a single 30 mg oxycodone tablet. This note was written by Nurse #4. Review of Resident #98's Medication Administration Record from December 2025 revealed the last dose of Oxycodone 30 mg tablet was signed as being provided to Resident #98 at 2:49 PM on 12/17/25 by Nurse #4. Review of Resident #98's Controlled Medication Utilization Record for Resident #98's 30 mg Oxycodone tablets dated 12/17/25 revealed 2 doses of Oxycodone 30 mg tablets were signed out after Resident #98 was sent out to the hospital. One dose was signed out by Nurse #4 on 12/17/25 at 6:00 PM and another dose was signed out on the same date with an unreadable time with an unreadable signature. Multiple attempts to reach Nurse #4 via telephone call on 02/18/26 and 02/19/26 were unsuccessful. An interview with the Director of Nursing on 02/19/26 at 4:55 PM revealed she was familiar with the incident and reported she had investigated this potential diversion of Resident #98's medication. The Director of Nursing reported Resident #98 was sent out to the hospital on [DATE] and after he was discharged , she requested after Resident #98 left (time unknown) that his medications be pulled from the medication cart so they could be sent back to the pharmacy. She stated she could not recall who brought her Resident #98's medication but reported while she was reviewing the medications and the controlled medication utilization records, she noted there appeared to be 2 doses of Resident #98's 30 mg Oxycodone that were dispensed after Resident #98 discharged from the facility. She stated at that time she notified the Former Administrator. She reported she and the former Administrator attempted to reach Nurse #4 multiple times, but Nurse #4 continued to have reasons she could not talk or come to the facility. The Director of Nursing stated she did receive a text from Nurse #4 which was a statement of what led to Resident #98 being discharged to the hospital, but nothing was said about why she appeared to have signed out at least one dose of Resident #98's 30 mg Oxycodone after he discharged to the hospital. When the Director of Nursing reached out for an explanation, Nurse #4 never responded. The Director of Nursing reported Nurse #4 was ultimately terminated due to what appeared to be her dispensing medications for a resident who was not in the building at the time they were dispensed and for failure to respond to the investigation inquiries. The Director of Nursing stated she was confident that Nurse #4 had, at least, signed out one of the doses of Resident #98's 30 mg Oxycodone. An interview with the Former Administrator on 02/19/26 at 6:27 PM revealed he remembered there was an issue with Nurse #4 and they believed she had diverted some opioid medications from a resident at the facility. He reported he did recall Nurse #4 not being very cooperative with the investigation and was ultimately terminated. He reported that he believed that the incident and Nurse #4 were reported to the Board of Nursing and apologized but stated he could not recall much else regarding the investigation. 2. Resident #53 was initially admitted to the facility on [DATE] with a readmission date of 01/15/26. A physician order for Resident #53 dated 11/21/25 read: oxycodone (an opioid pain medication) 15 milligrams (mg), one (1) tablet by mouth every 6 hours, scheduled for pain. A review of Resident #53's medication administration record (MAR) from December 2025 revealed oxycodone 15 mg, one (1) tablet by mouth, was administered as ordered from 12/05/25 through 12/10/25. The times of administration were: 6:00 PM, 12:00 AM, 6:00 AM, and 12:00 PM Resident #102 was admitted to the facility on [DATE] with diagnoses which included chronic pain and opioid dependence. A review of Resident #102's physician's orders revealed an order dated 11/04/25 for oxycodone 15 mg one (1) tablet by mouth twice daily scheduled. A review of the completed controlled substance accountability record for Resident #102 dated 11/30/25 for oxycodone 15 mg immediate release tablets, revealed that Resident #53 was administered oxycodone 15 mg per the physician order using Resident #102's supply of oxycodone 15 mg from 12/05/25 at 6:00 PM through 12/10/25 at 12:00 PM by multiple nurses. Nurses documented that medication was borrowed for Resident #53. During the time frame 12/05/25 to 12/10/25 the following nurses documented that they borrowed oxycodone 15 milligrams from Resident #102 for Resident #53: Nurse #9, Nurse #7, Nurse #5, Nurse #11, and the Unit Manager. A total of 20 tablets were borrowed from Resident #102's medication supply for Resident #53. A telephone interview with Nurse #7 who was no longer employed at the facility was conducted on 2/20/26 at 2:18 PM. Nurse #7 had documented borrowing oxycodone from Resident #102 for Resident #53 on 12/06/25 at 12:00 AM and 5:00 AM. Nurse #7 stated she could not recall those incidents when oxycodone had to be borrowed. She verbalized that it was common for controlled medications not to be available and to have to be borrowed from another resident. Nurse #7 indicated that nurses were supposed to notify the Director of Nursing (DON) when they borrowed medication, but she did not know how the controlled substances borrowed were replaced or reimbursed. Nurse #7 stated she had not notified the DON before she borrowed the oxycodone from Resident #102 for Resident #53. An interview with the Unit Manager was conducted on 2/24/26 at 9:39 AM. The Unit Manager stated that she remembered signing out several doses of oxycodone from Resident #102's card for Resident #53 because Resident #53's oxycodone prescription had run out. The Unit Manager documented that she borrowed oxycodone 15 mg from Resident #102 for Resident #53 on 12/08/25 at 12:00 PM, 12/09/2025 at 12:00 PM, and 12/10/25 at 12:00 PM. The Unit Manager recalled that Resident #53 required a hard script (a printed order with the provider's signature) for his oxycodone to be refilled in December 2025. The prescription was sent in, but there had been a billing issue which she was aware of because Resident #53's insurance required a prior authorization, and the medication was not delivered from the pharmacy before his supply ran out. Because Resident #53's own oxycodone supply had been exhausted, they borrowed from Resident #102 until Resident #53's prescription could be refilled. The Unit Manager verbalized that there had been a backup supply of oxycodone 5 mg tablets in the facility, but since Resident #53 received 15 mg, they borrowed from Resident #102, who had the same dosage, and she did not attempt to get it out of the backup supply. The Unit Manager stated that it was common for nurses to borrow controlled substances if they ran out from the pharmacy, although borrowing should only have been done upon approval of the DON. The Unit Manager stated that she did not speak with the DON prior to borrowing, nor did she notify the DON that Resident #53's oxycodone had not been received from the pharmacy. The Unit Manager stated that the process for ordering controlled substances was to reorder when the supply was getting low. The refill could be reordered directly from the pharmacy through the medication administration record (MAR). If there were no refills left, the pharmacy required a hard script. The Unit Manager indicated that although the medication might be ordered by one nurse, if that nurse did not work on the same hall every day, the order might not be followed up on. Some refills required prior authorization, and the DON completed those. The Unit Manager stated she did not review the controlled substance accountability records, but those sheets went to the DON. The Unit Manager verbalized she did not know how medication that was borrowed from one resident for another would be replaced, but she believed the DON handled that. An interview was conducted with the DON on 2/24/26 at 4:32 PM. The DON verbalized that there was no policy for borrowing controlled substances from one resident for another. The DON explained that she had not been aware that controlled substances were borrowed so frequently. The DON stated that nurses were not to borrow medications. The DON indicated that nurses had borrowed medications including controlled substances in the past but were supposed to notify her for approval. The DON stated that she had only received two to three phone calls over the last few months to approve borrowing medication. The DON reported that controlled substances should have been delivered from the pharmacy prior to any residents running out. However, even though controlled substances might be ordered, the pharmacy would not fill them for various reasons, including billing issues. If residents ran out of medication, the nurse should have called the provider for an order. Resident #53's insurance required the facility to complete a prior authorization for every refill of his medications, and that often-caused delays in orders, which had been an ongoing issue. The DON confirmed she completed the prior authorizations. Residents whose medications required prior authorization appeared as an alert on the pharmacy website page, which the DON checked daily. Prior authorization required several steps in the process, and this was usually what caused delays in controlled substance medication refills. Sometimes the provider did not complete their forms, or the pharmacy rejected the request without providing a reason. If the prior authorization was approved, sometimes the pharmacy automatically sent the controlled substance, but sometimes it did not, and the staff had to call the pharmacy to request delivery. The DON reported that she reviewed the controlled substance accountability records when they were returned to her after the medication was completed. She stated she did not review Resident #102's controlled substance accountability record dated 11/30/25 when it was returned but declined to state why she had not reviewed it. The DON indicated that if the nurses told her they borrowed medication, she would call the pharmacy to get the medication replaced. The DON could not produce records showing that Resident #53's oxycodone 15 mg had been reordered, delivered, or that Resident #102 had been reimbursed for the borrowed oxycodone. An interview with the Regional Nurse Consultant was conducted on 02/24/26 at 11:24 AM. He stated the facility followed all pharmacy policies related to controlled substances. The Regional Nurse Consultant stated that he was unaware that nurses were borrowing controlled substances for other residents and they were not supposed to borrow controlled substances. An interview with the Administrator was conducted on 2/24/26 at 6:12 PM. The Administrator stated that any concerns with the administration and documentation of controlled substances, including borrowing, should have been addressed by nursing leadership immediately. The Administrator verbalized that she would have expected the nurses to reorder controlled substances prescribed for all residents in a timely manner so they would not run out. If medication was not available from the pharmacy, the nurse would have been expected to call a provider for directions. If it was a billing issue, that should have been addressed quickly so the residents could receive their medication. A telephone interview with the Consultant Pharmacist was conducted on 02/25/26 at 2:44 PM. The Consultant Pharmacist reported that she performed the medication audits monthly. The audits consisted of checking all the medication carts, reviewing the controlled substance accountability records and reconciling it to the MAR and controlled substances inside the medication cart. She randomly selected a few residents to review records to ensure correct documentation was completed. The Consultant Pharmacist stated that the facility had a history of controlled substance documentation discrepancies and had been an ongoing issue at the facility. However, she had not noticed nurses borrowing from other residents on the controlled substance accountability records. The Consultant Pharmacist indicated she was not familiar with how the facility handled the process for borrowed controlled substances. When asked if borrowing controlled substances from one resident to the other violated pharmacy policy, the Consultant Pharmacist declined to answer but stated it violated best practice. 3. Resident #74 was admitted to the facility on [DATE]. A physician's order for Resident #74 dated 10/28/25 read: oxycodone (an opioid pain medication) 10 milligrams (mg), one (1) tablet by mouth every 4 hours as needed for pain. Do not give 1 hour prior to or after scheduled oxycodone. A review of Resident #74's medication administration record from December 2025 revealed oxycodone 10 mg by mouth every 4 hours as needed for pain was administered to Resident #74 on the following dates and times: on 12/22/25 at 10:29 AM, on 12/28/25 at 4:34 PM, on 12/29/25 at 9:30 AM and 5:40 PM, and on 12/30/25 at 9:16 AM and 5:54 PM. Resident #102 was admitted to the facility on [DATE]. A review of Resident #102's physician's orders revealed an order dated 09/23/25 for oxycodone 5 mg one (1) tablet by mouth every 24 hours as needed for pain. A review of the completed controlled substance accountability record dated December 2025 for Resident #102 for oxycodone 5 mg tablets revealed that Resident #74's prescribed oxycodone dose of 10 mg was administered using 2 tablets of Resident #102's 5 mg oxycodone tablets by multiple nurses. Nurses documented the medication was borrowed for Resident #74 on the controlled substance accountability record for Resident #102. The following staff documented on the controlled substance accountability record for Resident #102 that they borrowed oxycodone 5 mg tablets for Resident #74, the Unit Manager, Nurse #9, and Nurse #8 during December 2025. A total of 12 tablets were borrowed from Resident #102's medication for Resident #74. An interview with the Unit Manager was conducted on 02/24/26 at 9:39 AM. The Unit Manager stated she remembered she signed out several doses of oxycodone from Resident #102 for Resident #74 because Resident #74 was out of her oxycodone prescription. The Unit Manager documented on Resident #102's control substance accountability record for December 2025 that she borrowed oxycodone 5 mg from Resident #102 for Resident #74 on 12/22/25 at 10:29 AM 2 tablets, 12/29/25 at 9:30 AM 2 tablets, and 12/30/25 at 9:16 AM 2 tablets. The Unit Manager could not recall why Resident #74 was out of her medication but because Resident #74's own oxycodone supply had been exhausted, they borrowed from Resident #102 until Resident #74's could be refilled. The Unit Manager verbalized that there was a backup supply of oxycodone 5 mg tablets, and she could not explain why she did not obtain it from the backup supply and instead borrowed it from Resident #102. The Unit Manager stated it was common for nurses to borrow controlled substances if they ran out. She stated that even though she borrowed the medication, she did not speak with the Director of Nursing (DON) for approval. The Unit Manager stated the process to order controlled substances were if the supply ran low, it could be reordered directly from the pharmacy. If there were no refills left, the pharmacy would require a hard script. The Unit Manager indicated that although the medication might be ordered by one nurse, if they did not work on the same hall every day, it may not be followed up on. Some refills required prior authorization, and the DON completed that. The Unit Manager stated she did not review the controlled substance accountability records, but those sheets all went to the DON when completed. The Unit Manager verbalized she did not know how medication borrowed from one resident for another would be replaced, but she thought the DON handled that. An interview with the Regional Nurse Consultant was conducted on 02/24/26 at 11:24 AM. He stated the facility followed all pharmacy policies related to controlled substances. The Regional Nurse Consultant stated that he was unaware that nurses were borrowing controlled substances for other residents and they were not supposed to borrow controlled substances. An interview was conducted with the DON on 02/24/26 at 4:32 PM. The DON verbalized there was no policy to borrow controlled substances from one resident for another. The DON explained she was not aware controlled substances were borrowed so frequently. The DON stated the nurses were not to borrow medications. The DON indicated nurses had borrowed controlled medications in the past but were supposed to notify her for approval. The DON stated she had only received 2–3 phone calls over the last few months to approve borrowed medication. The DON reported controlled substances should have been delivered from the pharmacy prior to any residents running out. However, even though controlled substances might be ordered, the pharmacy did not fill them for various reasons, including billing issues. If they ran out of medication, the nurse should have called the provider for direction. The DON stated residents with certain insurance plans/company required the facility to complete a prior authorization for every refill of their medications, and that often caused a delay in orders; that had been an ongoing issue. The DON stated she was not sure if Resident #74 required prior authorization. The DON confirmed she completed the prior authorizations. The residents whose medications required prior authorization showed up as an alert on the pharmacy website page, which the DON checked daily. Prior authorization required several steps in the process, and this was usually what caused delays in controlled substance medication refills. Sometimes the provider did not complete their forms, or the pharmacy rejected it but did not provide a reason. If the prior authorization was approved, sometimes the pharmacy automatically sent the controlled substance, but sometimes it did not, and the staff would have to call the pharmacy to get them to deliver it. The DON reported she reviewed the controlled substance accountability records when they were returned to her after the medication was completed. She stated she had not reviewed Resident #102's December 2025 controlled substance accountability record when it was returned but declined to say why she had not reviewed it. The DON indicated that if the nurses told her they borrowed, she would call the pharmacy to get the medication replaced. The DON could not produce records of Resident #74's oxycodone 10 mg being reordered, delivered, or that Resident #102 had been reimbursed for the borrowed oxycodone. An interview with the Administrator was conducted on 02/24/26 at 6:12 PM. The Administrator stated any concerns with the administration and documentation of controlled substances, including borrowing, should have been addressed by nursing leadership immediately. The Administrator verbalized she would have expected the nurses to reorder controlled substances prescribed for all residents in a timely manner so they would not run out. If medication was not available from the pharmacy, the nurse would have been expected to call a provider for direction. If it was a billing issue, that would have been addressed quickly so the residents would receive their medication. A telephone interview with the Consultant Pharmacist was conducted on 02/25/26 at 2:44 PM. The Consultant Pharmacist reported that she performed the medication audits monthly. The audits consisted of checking all the medication carts, reviewing the controlled substance accountability records and reconciling it to the MAR and controlled substances inside the medication cart. She randomly selected a few residents to review records to ensure correct documentation was completed. The Consultant Pharmacist stated that the facility had a history of controlled substance documentation discrepancies and had been an ongoing issue at the facility. However, she had not noticed nurses borrowing from other residents on the controlled substance accountability records. The Consultant Pharmacist indicated she was not familiar with how the facility handled the process for borrowed controlled substances. When asked if borrowing controlled substances from one resident to the other violated pharmacy policy, the Consultant Pharmacist declined to answer but stated it violated best practice. 4. a. The Monthly Storage Audit form dated 09/24/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments noted, shift change blank on all carts. Another entry read, medication count reconciles with controlled substance accountability record (a comparison performed by reviewing the controlled substance accountability records and then verifying the administering nurse documented that medication was administered on the Medication Administration Record (MAR)). Not met with the following comments: E hall shift change medication count reconciliation sheet dated 09/18/25 had a discrepancy: 62 cards were documented by oncoming nurse. 8 cards were removed. 53 cards were documented at the end of the shift, but the card count should have been 54. Resident #98 had a physician's order for oxycodone (an opioid pain medication). 29 doses were signed on the controlled substance accountability record and only 27 doses were documented on Resident #98's MAR as administered. Resident #35 had a physician's order for tramadol (an opioid pain medication). 13 doses were signed on the controlled substance accountability record, and only 12 doses were documented on Resident #35's MAR as administered. b. The Monthly Storage Audit form dated 10/21/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments for missing nurse signatures noted on all medication carts. Another entry read, medication count reconciles with controlled substance accountability record. Not met with the following comments: Several missing nurse signatures on the controlled substance accountability record (no residents were named). Several controlled substance accountability record numbers did not add up correctly and were hard to follow (no resident names provided). On B hall medication cart, a nurse had documented 11 medication cards were present, but there were 16 medication cards. As needed (PRN) substances were administered before the next dose should have been administered (no specific incidents mentioned). c. The Monthly Storage Audit form dated 11/19/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments noted, missing nurse signatures on halls B, C, and D. Another entry read, medication count reconciles with controlled substance accountability record. Not met with the following comments: Resident #100 had a physician's order for oxycodone. Between 11/12/25 and 11/18/25 there were 19 doses signed on the controlled substance accountability record, but only 17 doses were documented on the MAR. The 11/17/25 as needed dose of oxycodone was administered too early for Resident #100. Resident #37 had a physician's order for hydrocodone/acetaminophen (an opioid pain medication) every 6 hours as needed. The 11/16/25 PRN dose was administered at 12:25 PM and again at 4:40 PM. d. The Monthly Storage Audit form dated 12/23/25 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read in part, shift change count properly documented. Not met with the following comments for missing nurse signatures noted on all medication carts. Another entry read medication count reconciles with controlled substance accountability record. Not met with the following comments: Resident #61 had a physician's order for lorazepam (a psychoactive medication which treats anxiety) as needed. 2 doses were signed on the controlled substance accountability record and were not documented on Resident #61's MAR as administered. Resident #97 had a physician's order for lorazepam as needed. One dose was signed on the controlled substance accountability record but was not documented on Resident #97's MAR as administered. Resident #13 had a physician's order for lorazepam as needed. 12 doses were signed on the controlled substance accountability record but only 5 doses were documented on Resident #13's MAR as administered. Resident #32 had a physician's order for lorazepam as needed. A dose dated 11/25/25 and 11/26/25 were wasted without a witness signature. e. The Monthly Storage Audit form dated 01/20/26 and completed by the Consultant Pharmacist revealed the facility had not met 2 pharmacy requirements under Controlled Substances. The document read: shift change count properly documented for missing nurse signatures noted on hall A, C, D, and E. Another entry read medication count reconciles with controlled substance accountability record. Not met with the following comments: Resident #82 had a physician's order for oxycodone. 6 doses that were signed on the controlled substance accountability record were not documented on Resident #82's MAR as administered. Resident #6 had a physician's order for tramadol. 2 doses were signed on the controlled substance accountability record were not documented on Resident #6's MAR as administered. Resident #75 had a physician's order for hydrocodone/acetaminophen. 3 doses were signed on the controlled substance accountability record and were not documented on Resident #75's MAR as administered. An interview with Regional Nurse Consultant was conducted on 02/24/26 at 11:24 AM. He stated that the facility followed all pharmacy policies related to controlled substances. The Regional Nurse Consultant reported that he was not aware of the pharmacy audit findings. An interview with the Director of Nursing (DON) was conducted on 02/24/26 4:32 PM. The DON stated that the Consultant Pharmacist performed medication storage audits monthly. They would speak to the DON and the Administrator when they arrived, and the audit took 1 to 1.5 hours to complete. The DON indicated that the Consultant Pharmacist would discuss the findings with the DON after the audit was completed. The DON verbalized she was not aware of any of the controlled substance concerns. She stated the only thing reported by the Consultant Pharmacist was that there were holes in the MAR with the controlled substances where nurses had not signed the medication was administered and that was the extent of the conversation. The DON could not recall the date that conversation occurred. The DON reported the Consultant Pharmacist was included in QAPI (Quality Assurance and Performance Improvement) meetings and had not mentioned any controlled substance documentation discrepancies during QAPI. The DON verbalized she was unaware that nurses were wasting controlled substances without a second nurse signature. The DON verbalized she had not reviewed the monthly pharmacy medication storage audits but could not explain why these were not reviewed. The DON stated that she was unaware of discrepancies with the controlled substance accountability records and nurses signing the MAR that the medication was administered. The DON explained she reviewed the controlled substance accountability record sheets when they were returned to her after the medication was completed. The DON stated she had not noted discrepancies, and she had not gone through and performed a full reconciliation. She indicated she did not really audit the nurses, but occasionally performed the shift change count with them as a form of monitoring. The DON could not provide documentation that this action occurred. The DON stated there had been no discrepancies when she had performed the shift change count. An interview with the Administrator was conducted on 02/24/26 at 6:12 PM. The Administrator stated that she was not aware of the controlled substance issues noted on the medication storage audits. The Administrator verbalized any concerns with the administration and documentation of controlled substances in the building identified by the pharmacy audits should have been addressed by nursing leadership immediately. The Administrator verbalized she would expect the nurses to verify accurate controlled substance counts at shift change, accurately document all controlled medications administered on the MAR, obtain witnesses for wasting controlled substance per policy, maintain accurate records on the controlled substance accountability record, and report any discrepancies to her immediately. A telephone interview with the Consultant Pharmacist was conducted on 02/25/26 at 2:44 PM. The Consultant Pharmacist reported that she performed the medication au

Based on record reviews, resident and staff interviews, and Psychiatric Nurse Practitioner (NP) the facility failed to refer one resident with a new mental health diagnosis for Preadmission Screening and Resident Review (PASRR) level II for 1 of 1 resident for PASRR (Resident #31).The findings included:A PASRR level I was completed on 10/29/2025 prior to Resident #31's admission to the facility with a recommendation to resubmit paperwork for PASRR level II if a new mental health diagnosis was suspected or if there was a significant change in the resident's condition.Review of the hospital Discharge summary dated [DATE] revealed Resident #31 experienced hallucinations and was talking to the ceiling. Resident #31 received haloperidol (antipsychotic used to treat schizophrenia) 1 milligram (mg) twice a day for agitation and quetiapine (atypical antipsychotic used to treat schizophrenia) 50 mg twice a day and 100 mg at bedtime with no indication for use documented. Resident #31 was evaluated by the hospital psychiatrist, and the quetiapine was discontinued and loxapine (antipsychotic mainly used to treat schizophrenia) 10 mg twice a day was initiated. Resident #31's discharge orders included follow up with the facility psychiatrist and continue haloperidol 1 mg twice a day for agitation, loxapine 10 mg twice a day, and buspirone (medication used to treat anxiety) 15 mg three times a day. The hospital discharge did not reveal that Resident #31 had a diagnosis of schizophrenia. Review of Resident #31's electronic medical record (EMR) revealed Resident #31 was admitted to the facility on [DATE]. Resident #31 had no mental health diagnoses when he was admitted to the facility.A psychiatry visit note dated 01/09/2026 revealed Resident #31 served in the military and then later served with the Central Intelligence Agency (CIA). Resident #31's military history was confirmed by his family member. During the visit Resident #31 stated that I lost it at the hospital, and I started seeing things that were not there, became delusional and blacked out. Resident #31's family member reported that he had hallucinations and paranoia while in the hospital which resulted in a nurse in the hospital being physically injured by Resident #31. Resident #31 denied any signs or symptoms of anger or anxiety during the visit. No emotional or behavioral outburst have occurred since Resident #31 arrived at the facility.Review of the electronic medical record (EMR) revealed Resident #31 was diagnosed with paranoid schizophrenia on 01/13/2026. There was no evidence in the medical record that a request was submitted for a Level II PASRR evaluation.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had moderately impaired cognition and the MDS coding indicated he had a level I PASRR. The MDS revealed Resident #31 had schizophrenia and he had received antipsychotics, anti-anxiety medications, and anticonvulsants during the 7 day look back period.An interview was conducted with Resident #31 on 2/17/2026 at 9:04 AM. Resident #31 stated that he had served in the military for 13 years and was stationed in Bosnia and Afghanistan. He further explained that he had suffered with mental illness since his return from active military duty and had night terrors related to his war experiences. Resident #31 further explained that he has received psychiatry counseling for many years. Resident #31 could not recall when he was first diagnosed with paranoid schizophrenia. A telephone interview was conducted on 02/18/2026 10:51 AM with the Psychiatric NP who cared for Resident #31. The Psychiatric NP stated that during his initial visit with Resident #31 on 01/09/2026, Resident #31 stated that he was a veteran and suffered from paranoid schizophrenia and had a long standing history of mental illness related to his military experiences. The Psychiatric NP stated that Resident #31's history was verified with his family member and further stated that Resident #31 was managing very well on his current medication regimen. The Psychiatric NP stated that Resident #31 should have been evaluated for a level II PASRR due to his mental health history.An interview was conducted with the MDS Coordinator on 02/17/2026 at 12:57 PM. The MDS Coordinator stated that she identified Resident #31's diagnosis of paranoid schizophrenia on a psychiatric note dated 01/09/2026. The MDS Coordinator stated that Resident #31 did not have a diagnosis of paranoid schizophrenia on his hospital Discharge summary dated [DATE]. The MDS Coordinator explained that she did not have access to request Level II PASRR evaluations, but she passed the information along to the previous Social Worker (SW) who was no longer employed with the facility. The MDS Coordinator could not recall when she passed the information to the previous SW. The MDS Coordinator further revealed that the previous SW did not have access to request Level II PASRR evaluations and the only person in the facility who had access was the Assistant Business Office Manager. The MDS Coordinator stated that she thought the SW passed the information along to the Assistant Business Office Manager. Multiple unsuccessful attempts to contact the previous SW were made.An interview was conducted with the Assistant Business Office Manager on 02/17/2026 at 1:27 PM. The Assistant Business Office Manager stated that she had not received any information or request to submit a request for a Level II PASRR evaluation for Resident #31. The Assistant Business Office Manager stated that she usually received that information during the morning clinical meetings.During an interview on 02/18/26 at 1:08 PM with the Administrator, she communicated her understanding that PASRR level II evaluations should be completed in a timely manner upon the admission of a resident with a mental health diagnosis and anytime a resident has had a change of condition or received a new mental health diagnosis. The Administrator stated that Resident #31 should have had a PASRR level II evaluation submitted when the diagnosis of paranoid schizophrenia was added to his diagnoses. The Administrator further stated that she did not know why the referral for a level II PASRR was not submitted for Resident #31.

Based on record review, and staff interviews, the facility failed to protect a resident's right to be free from misappropriation of resident narcotic medications for 1 of 4 resident reviewed for misappropriation of resident property (Resident #62).Findings included:Resident #62 was admitted to the facility on [DATE].Review of Resident #62's physician orders revealed an order for 5 milligram (mg) oxycodone HCl oral tablet (an opioid pain medication) with one tablet to be administered by mouth every 12 hours for pain. This order was dated 06/06/25. Additionally, Resident #62 had another order for 5mg oxycodone HCl oral tablet with one tablet to be administered by mouth every 6 hours as needed for breakthrough pain. This order was dated 06/06/25 and discontinued on 09/04/25.Review of the facility's record of a pharmacy delivery notification revealed Resident #62 had a pharmacy order that included 2 cards of 30 tablets each of 5mg oxycodone immediate release tablets that were delivered by the pharmacy on 09/04/25. Additional review of the pharmacy delivery notification revealed it was signed as received by Nurse #3 at 10:38 PM.An interview with Nurse #3 on 02/18/2026 at 2:46 PM revealed she worked 2nd shift most of the time. Nurse #3 stated when the pharmacy made a delivery of opioid or narcotic medications, the medications came in a sealed purple bag, and they were handed off to one of the nurses that was working at the time of the delivery. She continued, stating that the nurse who received the delivery would be responsible for verifying the medication and the amount delivered and would then sign off as having received the mediation. Nurse #3 verified that she was the nurse who signed for the pharmacy delivery of Resident #62's Oxycodone HCL medication on 09/04/25. Per Nurse #3, she distinctly remembered there were two, thirty pill count cards for Resident #62 that were delivered on 09/04/25 and that she verified the count and medication before signing off on the pharmacy's delivery sheet. Nurse #3 stated after she signed for the medication delivery, she delivered Resident #62's medication to the nurse (Nurse #4) who was assigned to Resident #62 that evening as she would need to complete two separate Controlled Drug Count Sheets one for each card of medication delivered. Nurse #3 stated she had no idea what happened to Resident #62's Oxycodone but stated it never made it to the medication cart as only one Controlled Drug Count Sheet was completed.Review of Resident #62's controlled drug count sheet dated from 08/31/25 through 09/06/25 revealed there were 41 cards of medications at shift change at 3:00 PM on 09/04/25 on the medication cart belonging to the hall where Resident #62 resided. Per the controlled drug count sheet, Nurse #4 was the oncoming nurse and verified that there were 41 cards of medications at that shift change. Additional review of the controlled drug count sheet revealed Nurse #4 signed off at 11:00 PM that there continued to be 41 cards of medication on the medication cart. There did not appear to be any addition or subtraction of medication cards while Nurse #4 was working. The 2 cards of Oxycodone that were delivered to the facility for Resident #62 on 09/04/25 were not added to the controlled drug count sheet by Nurse #4.Multiple attempts to reach Nurse #4 via telephone on 02/18/26 and 02/19/26 were unsuccessful. Nurse #4 was no longer an employee at the facility.An interview with the Director of Nursing (DON) on 02/19/26 at 5:11 PM revealed she was aware of Resident #62's 30 missing oxycodone tablets and indicated that she had assisted in the investigation. She reported she was initially informed of a discrepancy when a first shift nurse requested a refill for Resident #62's Oxycodone medication due to Resident #62 only having a few pills left on one card that was delivered on 09/04/25 and the pharmacy informed them they could not fill the prescription due to their records indicating that Resident #62 had 60 opioid (oxycodone) medications delivered 09/04/25 and it was too soon for the medication to be refilled as there should be at least 30 pills of the opioid medication still available. The Director of Nursing stated they searched the medication cart for the additional card of medication but were unsuccessful in locating it. The DON stated at that time, she reported the concern to the Former Administrator and the Regional Nurse Consultant. She was directed to count all the cards on all the facility's medication carts which was completed and reportedly found no discrepancies. The Director of Nursing also reported she reviewed 30 days of pharmacy deliveries with no discrepancies found. The Director of Nursing reported she interviewed Nurse #3 who had signed for the delivery and was reportedly told that Nurse #3 did not count or verify the medications and just signed the delivery paperwork and could not verify if 30 or 60 oxycodone tablets were delivered from the pharmacy. The Director of Nursing reported she spoke with multiple other staff members who were present at the time of the delivery but was unable to locate a staff member who could verify 2 cards (60 pills) of Oxycodone were delivered for Resident #62 on 09/04/25. The Director of Nursing reported she had no idea whether the pharmacy failed to bring both cards (60 tablets) of Oxycodone medications for Resident #62 or if one of the two Oxycodone medication cards went missing between delivery by the pharmacy and delivery to the medication cart.An interview with the Former Administrator, who was the Administrator at the time of the incident on 09/04/25, was completed via telephone on 02/19/26 at 6:31 PM. The Former Administrator stated it was hard to remember this incident as he believed it occurred shortly after he started. He stated he believed the Director of Nursing reported to him that there was some missing medication and when they began investigating, it seemed to had been going on for a couple weeks before it was discovered. The Former Administrator reported he recalled that the situation was discovered when a nurse went to try and reorder an Oxycodone medication for Resident #62 and the pharmacy reported it was too early to refill. He stated he remembered this investigation centered around Nurse #4 as she was the nurse assigned to the medication cart the Oxycodone medication went to after delivery. However, he stated they were ultimately unable to determine what actually happened to the missing card of medication and that they ordered another card of opioid medication at the facility's expense. He reported he had no further knowledge of the investigation due to him not being at the facility any longer.

Based on observations, record review, family member, and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 1 resident reviewed for foot care (Resident #63).The findings included:Resident #63 was admitted to the facility on [DATE] with diagnoses which included dementia, Parkinson's disease, and diabetes mellitus (DM).Review of the admission nursing assessment dated [DATE] did not reveal any issues with Resident #63's toenails.Review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition. Resident #63 required moderate assistant with bed mobility, toileting and transfers and required maximum assistant with bathing and dressing. The MDS also revealed Resident #63 had Parkinson's Disease, dementia, DM, and arthritis. The MDS indicated Resident #63 had no rejections of care and was at risk for pressure ulcer development. Review of Resident #63's care plan dated 12/10/2025 revealed one care plan was developed by the registered dietician (RD) related to the potential for nutritional problems. There were no other care areas addressed in Resident #63's care plan. Review of Resident #63's weekly nursing assessments from 12/03/2025 through 02/17/2026 revealed no notation that her toenails were long and thick and needed trimmed.Review of the facility's podiatry clinic schedule for 12/29/2025, revealed Resident #63 was not seen by the podiatrist. There were no consultation reports or notations in Resident #63's Electronic Medical Record (EMR) that she was scheduled to see the podiatrist or that she had been seen by a podiatrist since admission to the facility.An observation and interview were conducted on 02/16/2026 1:19 PM. Resident #63's toes revealed thick, long, jagged toenails on both feet. Resident #63's left great toenail had a brownish coloring at the base of the nailbed which had started to extend upward to the middle of the toenail. Resident #63 stated that her toenails looked nasty and she would like to have them trimmed. She explained that she had not been able to bend down and take care of her toenails and feet for a long time. She further explained that her daughter trimmed her toenails before she came to the facility. An observation and interview were conducted on 02/17/2026 11:24 AM with the wound nurse and the Assistant Director of Nursing (ADON). The wound nurse stated that she usually noticed resident's toenails when she provided wound care to their feet, but she did not notice Resident #63's toenails and she did not request for her to be added to the podiatry list. The ADON stated that Resident #63 would need to be seen by the podiatrist because she was diabetic and it would be best for the podiatrist to take care of her toenails. The ADON also stated that the facility's Social Worker usually added residents to the podiatry list, but the facility did not currently have a Social Worker. The ADON stated that she was responsible for adding residents to the podiatry schedule but added she had not referred Resident #63 to the podiatrist since her admission.An additional interview with Resident #63 and her family member was conducted on02/17/2026 2:28 PM. The family member stated Resident #63 had not been able to care for her feet and toenails in a long time. The family member explained that she used to keep Resident #63's toenails trimmed and groomed because Resident #63 was a diabetic and she knew how important it was too watch her feet for diabetic complications. Resident #63 stated that her toes did not hurt but she would like to have her toenails trimmed because they looked so bad.An interview was conducted with Nurse Aide (NA) #2 on 02/19/2026 8:19 AM who stated that she often gave Resident #63 her showers. NA #2 stated she had noticed Resident #63's toenails were very long and needed to be trimmed. NA #2 stated but to be honest, I don't remember if I told anyone about Resident #63's toenails. NA #2 further explained that she usually reported any concerns or issues to the resident's assigned nurse. An interview was conducted on 02/19/2026 4:36 PM with the DON & Administrator. The Administrator stated that she understood the concerns with Resident #63's toenails and explained that the nursing staff should observe resident's toenails when they completed their skin assessments and showers. She stated that she expected all residents to be referred to Podiatry services if needed, especially residents with diabetes.

Based on observations, record reviews, manufacturer's instructions, and staff and Consultant Pharmacist interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 4 medication errors out of 26 opportunities, resulting in a medication error rate of 15.38% for 2 of 3 residents observed during the medication administration (Resident #4 and Resident #85).The findings included:1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).Review of Resident #4's physician orders revealed orders for 1) fluticasone propionate nasal spray one spray in both nostrils one time a day for allergic rhinitis dated 05/02/23, 2) budesonide/glycopyrrolate/formoterol fumarate (steroid) inhaler 160-9-4.8 MCG/ACT (micrograms per activation) inhalation aerosol inhale 2 puffs two times a day for COPD. Rinse mouth with water after use. Do not swallow, dated 11/21/24, and 3) albuterol sulfate inhalation aerosol solution 108 (90 base) MCG/ACT inhale 2 puffs orally four times a day for COPD dated 03/30/23.Review of Resident #4's Minimum Data Set assessment dated [DATE] revealed her cognition was moderately impaired.On 02/17/26 at 9:19 AM an observation of a medication pass was made of Nurse #2 who was medicating Resident #4. Nurse #2 handed Resident #4 the nasal spray and the two inhalers and allowed the Resident to medicate herself without providing instructions of how to administer the medications. Resident #4 administered herself two sprays of nasal spray inhaler in each nostril, three puffs of the albuterol sulfate inhalation and after the Resident administered the 2 puffs of budesonide/glycopyrrolate/formoterol fumarate inhaler, the Nurse did not instruct the Resident to rinse her mouth with water.An interview was conducted with Nurse #2 on 017/26 at 12:51 PM. The Nurse was asked to review the medication pass for Resident #4 earlier that morning and the Nurse stated that he knew that the Resident gave herself too many puffs of the albuterol inhaler and the nasal inhaler. The Nurse stated he knew that he should have encouraged Resident #4 to rinse her mouth with water after she used the steroid inhaler but that normally she would be having her breakfast and drinking fluids when he gave her the inhalers and that morning, she had already had her breakfast, and he did not think about it. Nurse #2 stated the steroid inhaler could cause oral thrush and he should have encouraged the Resident to rinse her mouth with water.An interview was conducted with the Consultant Pharmacist on 02/17/26 at 2:10 PM who explained that the nurses should encourage the residents to rinse their mouths with water after each use of a steroid inhaler because of the possibility that they could develop oral thrush.During an interview with the Director of Nursing (DON) on 02/19/26 at 10:19 AM the DON explained that if Nurse #2 was going to let Resident #4 administer her inhalers, then he should have instructed her on how to give the inhalers. The DON stated Nurse #2 should have instructed the Resident to rinse her mouth with water after she administered the steroid inhaler. 2. The manufacturer's instructions for prefilled insulin pen indicated that priming the insulin pen each time was an important step to ensure there were no air bubbles in the insulin and the full dose of insulin was given. Priming the insulin pen: 1. Dial up 2 units: turn the dose selector dial to 2 units, 2. Prime the pen: Press the injection button to let out any air bubbles and ensure the insulin is flowing correctly, 3. Check for a drop of insulin: you should see a drop of insulin on the tip of the needle, 4. Repeat if necessary.Resident #85 was admitted on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #85's physician orders dated 02/17/26 revealed Lispro insulin give 8 units subcutaneously if the blood sugar was between 301 and 350 before each meal.On 02/17/26 at 12:05 PM an observation was made of Nurse #3 medicating Resident #85 via an insulin pen. The Nurse removed the Lispro insulin pen from the medication cart and set the counter to 8 units. Nurse #3 administered the 8 units of insulin without priming the insulin pen as advised by the manufacturer's instructions.An interview was conducted with Nurse #3 on 02/17/2026 at 12:05 PM. The Nurse was asked to explain the procedure when giving insulin using an insulin pen and Nurse #3 stated she gave the insulin by the five rights of giving any medication. When the Nurse was asked if she was aware of priming the insulin pen before giving the insulin the Nurse stated yes, I do remember that and realized that she did not prime the pen. She stated she should have primed the pen to 2 units to remove the air from the needle before she set the dial to 8 units. She indicated that she forgot to prime the pen.An interview was conducted with the Consultant Pharmacist on 02/17/2026 at 2:10 PM who explained that it was important to prime the needle when giving insulin via an insulin pen because it was important to remove the excess air from the needle to ensure the full dose of insulin was administered.During an interview with the Director of Nursing (DON) on 02/19/26 at 10:19 AM the DON stated Nurse #3 should have primed the insulin pen before administering the insulin to Resident #85.

Based on manufacturer guidelines, observations and staff interviews, the facility failed to label DuoNeb solution (inhalation breathing solution) with an open date for 1 of 3 medication carts (C and D medication cart) reviewed for medication storage.The findings included:Review of the manufacturer's guidelines for DuoNeb solution indicated: After opening the foil pouch individual vials of DuoNeb should be used within 14 days. On 02/17/26 at 2:30 PM an observation was made of the C and D medication cart accompanied by Nurse #1. The observation yielded an open and undated box of Duoneb solutions in the drawer of the medication cart and available for use. The delivery date on the box was 12/23/25.An interview was conducted with Nurse #1 on 02/17/25 at 2:30 PM who explained that the box of DuoNeb should be dated when opened because if the vials were not used within 7 days, then they should have been discarded. During an interview with the Director of Nursing (DON) on 02/19/26 at 10:30 AM the DON explained that the medication carts should be checked every day by the Nurse on the cart and making sure the DuoNeb solutions were dated was a part of the daily checks. The DON stated her expectation was that the Nurse who opened the box of DuoNeb solution should be the one who dated the box.

Based on observations, record review, and staff interviews, the facility failed to follow their Infection Control policy and Hand Hygiene policy when Nurse Aide #1 did not perform hand hygiene before applying clean gloves and Nurse Aide #1 nor the Unit Manager applied gowns while providing suprapubic catheter care on Resident #26. This deficient practice occurred for 2 of 7 staff members observed for infection control practices (Nurse Aide #1 and Nurse #4).The findings included:Review of the facility's policy and procedure entitled Hand Hygiene revised June 2025 read in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.Review of the facility's Enhanced Barrier Precautions policy last revised June 2025 read in part as follows: Enhanced barrier precaution (EBP) are utilized to reduce the transmission of multidrug resistant organisms (MDROs) to residents. EBP's employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include dressing, providing hygiene, and changing briefs. EBPs are indicated for residents with indwelling medical devices regardless of MDRO colonization. Indwelling medical devices include urinary catheters. EBPs remain in place for the duration of the resident's stay or until resolution or discontinuation of the indwelling medical device (catheter) that places them at risk.An observation of suprapubic catheter care was conducted on Resident #26 on 02/18/26 at 2:00 PM by Nurse Aide (NA) #1 and Nurse #4. Upon entering the Resident's room both staff removed gloves from the personal protective equipment (PPE) tower that was mounted on the Resident's door and applied the gloves but did not apply a gown. An enhanced barrier precaution sign that indicated the specific PPE required which was a gown and gloves was posted on the door. NA #1 removed the dirty dressing from the Resident's suprapubic site then removed her dirty gloves and applied clean gloves without sanitizing her hands. The NA cleaned the suprapubic site and catheter tubing then removed her dirty gloves and without utilizing hand sanitizer she applied clean gloves. Nurse #4 then applied a dressing to the suprapubic site and removed her gloves and washed her hands.An interview was conducted with Nurse Aide #1 on 02/18/2026 at 2:20 PM. The NA was asked what precautions Resident #26 was currently on and the NA explained that it was enhanced barrier precautions and that she should have worn a gown while providing care to Resident #26. The NA continued to explain that she realized that she did not wash her hands between gloves changes which she should have. She stated she was nervous and forgot. On 02/18/2026 at 2:40 PM during an interview with Nurse #4 the Nurse explained that she did not know what type of precautions Resident #26 was on until she pulled his information up on the computer during the interview. The Nurse continued to explain that the Resident was on enhanced barrier precautions, and she should have worn a gown. She stated she did not pay attention to the enhanced barrier precaution sign posted on the Resident's door and that she did not do anything to Resident #26 that would warrant wearing a gown.An interview was conducted with the Director of Nursing (DON) on 10/19/26 at 10:06 AM. The DON explained that NA and the Nurse should have worn a gown for enhanced barrier precautions and that NA #1 should have washed or sanitized her hands between glove changes. She indicated both staff needed to be reeducated on enhanced barrier precautions.

Based on record review and staff interviews, the facility failed to develop a care plan in the area of urinary catheter for 1 of 3 residents reviewed for care plans (Resident #99). The findings included:Resident #99 was admitted to the facility on [DATE] with diagnoses that included urinary retention. The Resident was discharged on 07/22/25.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #99 had an indwelling urinary catheter.Review of Resident #99's medical record revealed orders dated 06/23/25 for urinary catheter, change catheter as needed, change catheter bag as needed, catheter care every shift and as needed, place stat lock to secure catheter and to check placement every shift.Review of Resident #99's Treatment Administrator Record for June and July 2025 revealed the Resident had a urinary catheter and received daily care for the urinary catheter.Review of Resident #99's comprehensive care plan dated 07/03/25 revealed there was no mention of a urinary catheter on the care plan.During an interview with the MDS Coordinator on 02/26/26 at 5:15 PM the MDS Coordinator reviewed Resident #99's care plan and acknowledged the urinary catheter was not on the care plan. She continued to explain that during the time of Resident #99's admission to the facility the facility was undergoing a change in companies which included an electronic medical record upgrade, and it was possible that when she was completing the care plan the system did not accept her input of the care plan.An interview was conducted on 02/26/26 at 5:40 PM with the Administrator who stated that she expected all residents to have an accurate and complete comprehensive care plan and the care plan should reflect the resident's clinical condition, medications, and care needs.

Based on observations, record reviews, staff and resident interviews, the facility failed to assess Resident #62 for the ability to self-administer medications for 1 of 1 resident reviewed for self-administering medications.The findings included:Resident #62 was admitted to the facility on [DATE].Resident #62's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact.Review of Resident #62's physician orders revealed there were no orders for a calcium carbonate (Tums) medication.Review of Resident #62's medical record revealed there was no self-administer assessment. On 02/16/2026 at 10:19 AM an observation was made of Resident #62's room where there was a bottle of calcium carbonate (Tums) tablets on her bed which was approximately 1/4 full. Resident #62 was not in the room. On 02/16/2026 at 3:18 PM an observation of the bottle of calcium carbonate (Tums) tablets was sitting on the Resident's over bed table which was approximately 1/4 full. Resident #62 was not in the room. On 02/17/2026 at 10:30 AM an observation and interview were conducted with Resident #62. The Resident stated her family brought the bottle of Tums to her because she needed them when she had heartburn. She stated she did not take them often, but she wanted to be able to take them when she needed them. Resident #62 could not say when the last time was that she took the tablets. On 02/18/2026 at 11:13 AM an interview and observation were made in Resident #62's room with Nurse #4. The Nurse stated she did not know that Resident #62 kept the Tums tablets in her room. The Nurse explained that Resident #62 did not have an order to self-administer medications and that she believed Resident #62 would not be safe to self-administer because some days she could be lethargic because of her medications. Nurse #4 removed the bottle of medication from the Resident's room.An interview was conducted with the Director of Nursing (DON) on 02/19/26 at 10:40 AM. The DON explained that Resident #62 did not have an order to self-administer and that they would get an order for an antacid for her heartburn.

Based on observation, record reviews, family, and staff interviews, the facility failed to complete a Do Not Resuscitate (DNR) form (a DNR form is a legal document signed by the physician) for a resident with a DNR physician order (Resident #11) at admission. The facility also failed to ensure resident advanced directive information was consistent throughout the medical record (Resident #31 and Resident #62). This deficient practice occurred for 3 of 6 residents reviewed for advanced directives.Findings included: 1. Resident #11 was admitted to the facility on [DATE]. A review of Resident #11's physician orders revealed an order for advanced directive of do not resuscitate (DNR) dated [DATE]. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired. A review of Resident #11's electronic medical record (EMR) revealed the advanced directive banner at the top of Resident #11's EMR page documented that his advance directive was DNR. Review of the advanced directives notebook kept at the nurse's station revealed there were no advanced directives on file for Resident #11. On [DATE] at 3:28 PM an interview was conducted with Nurse #3 who was assigned to Resident #11 that day ([DATE]). Nurse #3 explained that if she had to immediately determine a resident's advanced directives, she would look at the resident's medical record on the computer and she would look in the advanced directives notebook kept at the nurse's station. Nurse #3 looked in the advanced directives notebook for Resident #11's DNR form and acknowledged the form was not in the book. Nurse #3 stated that she was unsure who completed the code forms when a resident was admitted . Nurse #3 indicated that the Assistant Director of Nursing (ADON) and Director of Nursing (DON) would be responsible for ensuring the code forms were in the notebook stored at the nurse's station. An interview was conducted with the DON on [DATE] at 3:43 PM. The DON explained that if a resident was a DNR then there should be a DNR form in the advanced directive notebook at the nurse's station in case of an emergency. The DON verbalized that Resident #11 was a DNR and verified on the EMR. The DON stated that the Social Worker was responsible for completing the advanced directive forms upon admission. The Social Worker was also responsible for audits of the advanced directive notebook to ensure the correct forms were in place. The DON explained that the previous Social Worker worked [DATE] through last week but was no longer employed at the facility. The new Social Worker began work today and would have no knowledge of Resident #11's advanced directive information. The DON verbalized she was unaware if the former Social Worker discussed advanced directives with Resident #11's family when he was admitted . The DON indicated Resident #11 was admitted from the hospital with an order for DNR, but she was unsure if the former Social Worker had a completed DNR form. An interview with the Administrator was conducted on [DATE] at 12:11 PM. The Administrator stated that the DNR forms should be available for facility and emergency staff in case a resident had an emergency. The Administrator verbalized that she would expect the staff to follow the physician's orders and all advanced directive information should match and completed accurately. The Administrator stated that the ADON and DON would be responsible for ensuring accurate code forms were placed in the advanced directive folder if there was no Social Worker available. 2. Resident #62 was admitted to the facility on [DATE]. Review of Resident #62's electronic health record revealed a physician's order dated [DATE] for Do Not Resituate (DNR). Review of Resident #62's care plan revised [DATE] revealed a Full Code status. The interventions included honoring the Resident's wishes and reviewing the (code status) with the Resident and/or family during quarterly care conferences. Review of Resident #62's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. Review of Resident #62's physician progress note dated [DATE] revealed the advanced directive status was Full Code Blue. Review of the code status notebook kept at the nursing desk revealed there was no advanced directive information in the notebook for Resident #62. On [DATE] at 12:11 PM during an interview with the Administrator, she explained that it was her expectation that the staff follow the advanced directives and the advanced directive information should be the same throughout the medical record. An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:36 PM. The DON explained that the advanced directive paperwork was initiated at admission and periodically audited by the Social Worker (SW) which included making sure the advanced directives were in place and matched in the medical records and in the code status notebook at the desk, but the SW resigned last week. The DON stated it was possible that the discrepancies happened during one of the Resident's admissions to the hospital. Regardless, the DON indicated the advanced directives should match throughout the medical record. During an interview with Nurse #3 on [DATE] at 9:10 AM the Nurse explained that if she had to determine what a resident's code status was, she would either look on the residents' profile page in their medical record (the profile page displays the residents' picture with their advanced directive listed underneath) or look in the code status notebook at the nursing desk. She indicated that if nothing was in the code status notebook then she would refer to the profile page in the medical record. An interview was conducted with the Unit Manager (UM) on [DATE] at 11:46 AM. The UM explained that if she had to determine a residents' code status in a hurry it would depend on if her computer was booted up and if so, she would look at the profile page where the advanced directive was listed under their picture. She continued to explain that if she was closer to the nursing desk she would look in the code status notebook. The UM stated the two areas should match. 3. Review of the hospital Discharge summary dated [DATE] revealed Resident #31's code status was No Cardiopulmonary Resuscitation (CPR) (DNR). Resident #31 was admitted to the facility on [DATE]. Resident #31's physician orders revealed an order dated [DATE] which indicated a Do Not Resuscitate (DNR) status in the event he had no pulse and was not breathing. Review of the code book (a binder that contained paper copies of residents' advanced directives and code status) revealed Resident #31's paper medical record indicated the Medical Orders for Scope of Treatment (MOST) form dated [DATE] stated a preference for Attempt Cardiopulmonary Resuscitate (CPR) in the event Resident #31 had no pulse and was not breathing. The form was signed by Resident #31's Responsible Party (RP) on [DATE]. The MOST form did not have a physician's signature. Review of the Advanced Directive Discussion Document located in the code book and completed by the Director of Sales and Marketing/admission Coordinator dated [DATE] revealed to provide Cardiopulmonary Resuscitation in the event Resident #31 had no pulse and was not breathing. The form was signed by Resident #31's RP on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #31 had moderately impaired cognition. Further review of Resident #31's electronic medical record (EMR) revealed a physician's progress note dated [DATE] that read in part: Code Status: Do Not Attempt Resuscitation (DNR/no CPR). An interview was conducted on [DATE] at 3:38 PM with Nurse #3 who stated that she does not check the code book unless there was an emergency. She explained that if there was an emergency, she would check the code book and the resident's EMR for the resident's code status. Nurse #3 revealed that she did not know who completed the advance directive information and code status when residents were admitted to the facility. Nurse #3 further explained that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were responsible for checking the code book. An interview was conducted with Resident #31 on [DATE] at 9:10 AM. Resident #31 stated that he had an advanced directive in place and that he and his RP had made the decision that he would not want any type of CPR. Multiple unsuccessful attempts to contact Resident #31's RP were made. An interview was conducted with the Director of Sales and Marketing/admission Coordinator on [DATE] 2:34 PM who stated that she had been completing the advanced directive discussions and paperwork with newly admitted residents and/or their RP since the facility did not have a current Social Worker (SW). She explained that she met with Resident #31's RP on [DATE] and Resident #31's RP completed the Advanced Directive Discussion Form and the MOST form. She further explained that Resident #31's RP indicated that she wanted Resident #31 to receive CPR on both documents. The Director of Sales and Marketing/admission Coordinator stated that she placed Resident #31's completed Advanced Directive Discussion Form and the MOST form in the code notebook (a binder that contained paper copies of residents' advanced directives and code status) at the nursing station. An interview was conducted on [DATE] 3:43 PM with the Director of Nursing (DON) who stated Resident #31's had not been deemed incompetent, and his RP had signed all of his admission paperwork including his Advanced Directive Discussion Form and his MOST form. The DON verified Resident #31's physician order in the EMR for a DNR did not match the Advanced Directive Discussion Form and the MOST form which indicated to provide CPR. The DON also verified that Resident #31's MOST form had not been signed by the physician. The Director of Nursing (DON) revealed the admission Coordinator completed the advanced directive forms because the facility did not have a current SW. The DON explained that the admission Coordinator placed the forms in the code notebook at the nursing station when she should have placed the forms in the physician's folder for review and signature. An interview was conducted on [DATE] 4:11 PM with the Administrator who stated she expected the staff to follow the advanced directive orders and that all advanced directive information should match and be correct in all locations including in the EMR and the code notebook at the nursing station. The Administrator further stated that if the advanced directive information did not match, she expected the staff to clarify the information with the resident and the RP to ensure the resident's wishes were honored.

Based on record review and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan for 1 of 6 residents whose comprehensive care plans were reviewed (Resident #63).The findings included:Resident #63 was admitted to the facility on [DATE] with diagnoses which included dementia, Parkinson's disease, and diabetes mellitus (DM).Review of Resident #63's admission Minimum Data Set (MDS) assessment dated [DATE] revealed moderately impaired cognition. Resident #63 required supervision with eating and bed mobility, moderate assistance with oral hygiene, toileting, and transfers, and required maximum assistance with bathing and dressing. The MDS also revealed Resident #63 was incontinent of bowel and bladder. Resident #63's MDS was coded for Parkinson's Disease, dementia, hypertension, diabetes, and arthritis. The MDS also indicated Resident #63 had no pain and no weight loss but received a therapeutic diet. She was at risk for pressure ulcer development and had no wounds. She had received anti-psychotic, anti-anxiety, and hypoglycemic medications during the 7 day look back period. The MDS also revealed Resident #63 was planning to discharge back to the community.Review of Resident #63's comprehensive care plan dated 12/10/2025 revealed one care plan entry was developed by the Registered Dietician (RD) related to the potential for nutritional problems. There were no other care areas addressed in Resident #63's comprehensive care plan.Review of the Care Area Assessments (CAA) (a tool used to identify relevant causes, risk factors and complications in order to develop a person-centered plan of care) completed by the MDS Coordinator on 12/12/2025 revealed Resident #63 triggered for the following CAAs: 1. Cognitive loss/Dementia2. Functional Abilities for Self-Care and Mobility3. Urinary Incontinence4. Psychosocial Well-being5. Activities6. Falls7. Nutritional Status8. Pressure Ulcer Injury9. Psychotropic Drug UseA review of Resident #63's care plan was completed on 02/18/2026 at 7:40 AM with the MDS Coordinator who verified the only care plan entry for Resident #63 was for nutrition which was completed by the RD. She further stated that she remembered completing Resident #63's comprehensive care plan and does not know what happened to her care plan. The MDS Coordinator also stated that she was aware that a comprehensive care plan should be developed within 21 days of the resident's admission to the facility. The MDS Coordinator further explained that the facility had two recent computer upgrades, and she thought something happened to Resident #63's care plan when the computer updates occurred. An interview was conducted on 2/18/2026 at 9:02 AM with the Administrator who stated that she expected all residents to have an accurate and complete comprehensive care plan and the care plan should reflect the resident's clinical condition, medications, and care needs.

Based on record review, observations, and interviews with the resident's responsible party, staff, and the Medical Director, the facility failed to supervise a severely cognitively impaired resident who demonstrated wandering behaviors in the facility and prevent him from entering into an unlocked kitchen door and then exiting the facility through the kitchen's exterior door for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Resident #1 who had a diagnosis of dementia exited from the facility without staff's knowledge for an undetermined length of time on the evening of 7/11/25 and was observed by staff through the door at the end of C hall standing by the facility's transport van parked outside the facility in the back parking lot in socked feet. There was the high likelihood of a serious adverse outcome for Resident #1, who had a diagnosis of dementia, when he entered the unlocked kitchen and walked through the kitchen and exited the facility through the kitchen's exterior door. Resident #1 could have wandered into and been entrapped in the walk-in freezer or walk-in cooler, been injured by contact with kitchen equipment, or experienced a fall or serious injury if he had wandered into the nearby wooded area or the 4-lane main highway.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included left femur fracture, abnormalities of gait and mobility, muscle weakness, and dementia.A review of the Elopement Risk Evaluation for Resident #1 dated 3/19/25 indicated Resident #1 had potential risk factors for elopement that included cognitive impairment, poor decision-making skills and ability to exit the facility, but he had no exit-seeking behaviors so Resident #1 was not considered at risk for elopement.The significant change in status Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired, but did not exhibit wandering behaviors during the assessment period. Resident #1 had range of motion impairment on one side of the lower extremities, used a wheelchair, and required substantial/maximal assistance with most activities of daily living including walking 10 feet. Resident #1 had one fall with no injury and one fall with minor injury since admission or prior assessment.Resident #1 did not have a care plan for wandering behaviors or risk for elopement prior to 7/11/25.A review of an Incident Report for Elopement dated 7/11/25 at 7:45 PM prepared by Nurse #1 indicated the nurse aide witnessed Resident #1 outside walking past C hall door. The nurse aide ran outside and assisted Resident #1 back inside the building. Nurse #1 assessed Resident #1 for any type of injury. There were none (injuries) to be found.A review of Resident #1's medical record indicated a late entry nursing progress note dated 7/12/25 at 3:29 PM by Nurse #1 which read, in part: Nurse Aide (NA) #1 and NA #2 witnessed Resident #1 outside, walking past the C hall door at approximately 7:45 PM. NA #1 immediately ran outside to assist him back into the building while NA #2 came and alerted Nurse #1. Nurse #1 assisted NA #1 with guiding Resident #1 back into the building via C hall door. NA #2 went to find Resident #1's wheelchair, finding it in the dining room just outside the door going into the kitchen. Once Resident #1 was assessed, Nurse #1 checked the doors and found all doors to be closed and locked. When NA #2 checked the kitchen door, she found it to be unlocked. Apparently, Resident #1 went through the unlocked kitchen door and outside through the back door of the kitchen. Nurse #1 notified the Director of Nursing as well as the Administrator who came to the facility shortly thereafter. A phone interview with NA #1 on 7/16/25 at 12:05 PM revealed she was talking to NA #2 when she noticed Resident #1 outside the facility through the door at the end of C hall on 7/11/25. Resident #1 was standing and holding onto the facility's transport van which was parked in the back parking lot. NA #1 stated that she immediately went out the C hall door to get Resident #1 while NA #2 alerted Nurse #1 who helped her walk Resident #1 back into the building. NA #1 stated Resident #1 was wearing long sleeves and pants, and she noticed that his face was red from being outside. NA #1 stated that she observed Resident #1 pulling on the van door, and she thought he was trying to get in the van. NA #1 asked Resident #1 what he was doing, and he just shrugged his shoulders at her, and did not say anything. NA #1 stated that Resident #1 moved around on his own in his wheelchair both by rolling his wheelchair and sometimes standing up and walking while pushing his wheelchair. NA #1 further stated that she wasn't assigned to Resident #1 on 7/11/25, and had not seen Resident #1 prior to him being outside. She shared that NA #3 and NA #4 were assigned to Resident #1, but they were doing their rounds when NA #1 saw Resident #1 outside the facility. NA #1 further shared that when NA #2 looked for Resident #1's wheelchair, she found it right at the interior kitchen door from the dining room which was unlocked, and they suspected he had gotten out through the exterior kitchen door on the left side close to the dishwasher because he had grass all over his socks, and that he must have walked through the grass outside that door. NA #1 stated that nobody was in the kitchen at that time because all dietary staff had already left for the day. An interview with NA #2 on 7/16/25 at 3:47 PM revealed she was talking to NA #1 when NA #1 saw Resident #1 outside the C hall door. NA #1 took off running to get Resident #1, and hollered to everyone that Resident #1 was outside. NA #2 stated that she observed Resident #1 standing by the facility's transport van, which was parked at the back parking lot, but his wheelchair was not out there. NA #2 stated she went back into the facility to get Resident #1's wheelchair and on the way to his room, NA #2 alerted Nurse #1 that Resident #1 was outside. NA #2 further stated that she checked Resident #1's room but his wheelchair was not there. NA #2 said that she found Resident #1's wheelchair in the dining room parked right by the interior kitchen door which was unlocked. NA #2 stated that the interior kitchen door from the dining room was normally locked and could not be accessed unless a code was entered on the door. NA #2 shared that only the dietary staff knew the code to the interior kitchen door. NA #2 shared that she walked into the kitchen and observed an unlocked exterior door on the left side close to the dishwasher leading to the outside. NA #2 further shared that she suspected Resident #1 walked out through this door because his socks were covered with grass, and they were wet.A phone interview with Nurse #1 on 7/18/25 at 7:50 PM revealed the elopement incident involving Resident #1 must have happened between 7:55 PM and 8:00 PM on 7/11/25, and she had been in the facility for about an hour. Nurse #1 stated that she last saw Resident #1 around 7:30 PM, and he was propelling himself in his wheelchair around the nurses' station. Nurse #1 stated that NA #1 and NA #2 both saw Resident #1 through the end of the C hall door. She further stated that she and NA #1 both ran to get Resident #1 while NA #2 looked for his wheelchair. Nurse #1 shared that Resident #1 was wearing long sleeves, pull-on pants, and socks. She said that Resident #1 was strong, but he couldn't stand upright well. As they were walking Resident #1 back inside, he was trying to pull away from them, and he acted like he did not want to sit down. While NA #2 was looking for Resident #1's wheelchair, they sat him down in the chair by the nurses' station so Nurse #1 could assess him. Nurse #1 stated she checked his skin to look for any signs of injuries and she found none. She checked his vital signs which were normal. Nurse #1 stated Resident #1 had grass on his socks which led them to believe he had gotten out through the exterior kitchen door leading to the back parking lot. Nurse #1 stated she called the Administrator and the Director of Nursing to notify them about the incident.An interview with NA #3 on 7/16/25 at 3:25 PM revealed she came in to work on 7/11/25 at 7:15 PM, and she was assigned to Resident #1's hall. NA #3 stated she saw Resident #1 in the dining room at 7:15 PM sitting in his wheelchair. NA #3 further stated as soon as she got to the facility, she was advised that all the nurse aides had to split D hall, so she and NA #4 went ahead and assisted a resident into bed on D hall. NA #3 stated that when they went down to Resident #1's hall and got ready to start their round, NA #4 heard another employee say that Resident #1 had gotten out of the facility. NA #3 stated that after staff got Resident #1 back into the facility, she put him in his recliner in his room, and then about 20 minutes before 9:00 PM, she assisted him to bed. NA #3 stated that she was glad NA #1 and NA #2 had turned around and saw Resident #1 through the door at the end of C hall. NA #3 stated that all staff had to lay eyes on Resident #1, because he liked to go to doors and mash on them. NA #3 added that she would often try to redirect Resident #1 whenever she saw him mashing on the hall doors. NA #3 shared that Resident #1 usually sat by the doors, and liked to look outside. She further shared that he normally wore non-skid socks, long-sleeve shirt, and pants. She said that Resident #1 was always confused, and she asked him what he was doing outside, but he did not answer her and just looked at her. A phone interview with NA #4 on 7/16/25 at 12:59 PM revealed when she walked in to work around 7:00 PM on 7/11/25, she saw Resident #1 in his wheelchair propelling himself around by the nurses' station. NA #4 stated that she was getting ready to do rounds on Resident #1's hall when she walked up to the nurses' station and NA #1 and NA #2 told her that they had found Resident #1 wandering by the facility van which was parked in the back parking lot. NA #4 stated the incident must have happened around 7:30 PM because it was not long after she had been in the facility. NA #4 stated that Resident #1 had wandering behaviors, and he was always walking or propelling around in his wheelchair. NA #4 stated that she had seen him near the doors at the end of A hall and C hall, and he often tried to push them open, but these doors wouldn't open. NA #4 shared that the interior kitchen door was supposed to be locked, and that there was a code to get in it. NA #4 stated that from what she heard, the interior kitchen door was left open and didn't close all the way.An interview with the Unit Manager (UM) on 7/16/25 at 2:22 PM revealed he was in the conference room between 7:00 PM and 8:00 PM on 7/11/25 when he heard commotion from staff. The UM stated he came out of the conference room and observed staff walking Resident #1 back into the facility. The UM stated that they brought Resident #1 into the nurses' station and Nurse #1 obtained his vital signs and did a skin assessment. The UM shared that he was assigned to two other halls that evening, and had seen Resident #1 occasionally wheeling himself around, but he couldn't remember the time he had seen him.An interview with the Dietary Manager (DM) on 7/16/25 at 1:24 PM revealed she had a cook and two dietary aides who worked the supper service on 7/11/25, and all of them left at 7:00 PM. The DM stated that they all reported that they locked all the doors to the kitchen before they left. The DM shared that there was one interior kitchen door coming from the dining room, and two exterior doors leading to the outside, and her staff said they made sure they locked all the interior and exterior kitchen doors. The DM stated that the interior kitchen door was locked through a code, while the two exterior doors were locked through a knob. She shared that her staff locked the exterior doors with a key from the outside, but it was easy to open from the inside just by turning the doorknob. An observation inside the kitchen on 7/16/25 at 1:15 PM revealed an industrial gas range with turn knobs, a sink and a dishwasher which were around 50 feet from the interior kitchen door. There were several cabinets and countertops with various kitchen gadgets, a walk-in freezer, a walk-in cooler, reach-in refrigerators, and multiple meal carts.An observation was made on 7/16/25 at 1:34 PM of the outside area from the kitchen door on the left side right by the dishwasher. Right outside the exterior door was approximately 50 feet of grassy area before reaching the side walk on the left side of the exterior door. The back parking lot and the end of the C hall door was approximately 85 feet from the exterior kitchen door. The 4-lane main road with a posted speed limit of 45 miles per hour (mph) was approximately 150 feet from the back parking lot at the end of the C hall door where Resident #1 was observed. There was a wooded area approximately 200 feet towards the right side from the exterior door. Behind the wooded area was ditch approximately three feet deep with a sharp incline.A review of the weather conditions per Weather Underground website revealed the following data for [NAME], North Carolina on 7/11/25 at 7:54 PM: 76 degrees Fahrenheit with no precipitation, Southeast wind speed at 3 mph. An interview with Resident #1's responsible party (RP) on 7/16/25 at 11:01 AM revealed Resident #1 had gotten out of the facility on the evening of 7/11/25 around 8:00 PM. Resident #1's RP stated that from what was reported to her, Resident #1 had wheeled himself into the dining room, opened the interior door to the kitchen, which was left unlocked, and went outside through an exterior door inside the kitchen. Resident #1's RP stated nobody knew how long Resident #1 was inside the kitchen or outside of the facility. The nurse and the nurse aides brought Resident #1 back in after they had seen him through a hall door. Resident #1's RP stated that she didn't find out about the incident until the next day, and it had upset her. She further stated that it scared her because something bad could have happened to Resident #1. She added that Resident #1 could have gotten hurt while he was unsupervised in the kitchen, as well as while he was outside by himself because the facility was right by a busy road. During the RP interview, an attempt was made to interview Resident #1, but he did not answer any questions. He was observed sitting in a wheelchair while facing the door at the end of A hall. Resident #1's RP stated that Resident #1 recognized her but did not talk much to her either. During an interview with the Maintenance Director on 7/16/25 at 2:17 PM, an observation of the interior kitchen door revealed he had removed the latch or the locking mechanism at the back of it. The Maintenance Director stated that it had been reported to him that on the evening of 7/11/25, the latch at the back of the interior kitchen door had been kept unlocked and this prevented it from requiring a code to unlock it. He stated that removing the latch prevented staff from keeping the interior kitchen door unlocked without having to enter a code on the keypad. He also stated that he had changed the code to the interior kitchen door on 7/15/25 and again on 7/16/25, because he found out that some nurse aides knew about the code to the interior kitchen door. The Maintenance Director stated that the nurse aides were not supposed to have the code to the kitchen, and that only kitchen staff should have access to the interior kitchen door. He also pointed out that he had removed the door stop to the interior kitchen door to prevent staff from propping it open during meal service. An interview with a Physical Therapist (PT) on 7/17/25 at 9:30 AM revealed physical therapy had worked with Resident #1 from 3/6/25 to 4/17/25 following repair of his left femur fracture. The PT stated that when Resident #1 was discharged from physical therapy, his mobility depended on the day, but he had walked up to 300 feet with contact guard which meant a staff member held onto a gait belt while he walked. The PT stated Resident #1 always had to have assistance with walking, but his dementia prevented him from remembering that it was unsafe for him to walk unassisted. The PT further stated that it was not safe for Resident #1 to walk on grass at the time of discharge from therapy. She also shared that Resident #1 always wore gripper socks because wearing shoes caused him to trip more, and he had better traction with gripper socks.A phone interview with the Medical Director (MD) on 7/17/25 at 9:37 AM revealed he was informed about Resident #1's elopement shortly after it had happened when he received a text message letting him know about Resident #1 getting outside the facility through an unlocked kitchen door. The Medical Director stated that it was an unfortunate coincidence that Resident #1 made it through a kitchen door to the outside of the facility. The Medical Director stated that it was not safe for Resident #1 to be outside unassisted. The Medical Director further stated that he could go on and on about the dangers of a resident with dementia being outside unsupervised, and that this caused a potential for serious harm. An interview with the Director of Nursing (DON) on 7/16/25 at 4:22 PM revealed she received a phone call from Nurse #1 that Resident #1 had gotten out of the building on 7/11/25. A nurse aide saw him outside and brought him back in. They assessed him and checked him for any signs of injuries, and he didn't have any. The DON stated that staff told her that Resident #1 exited through the kitchen because his wheelchair was found right at the interior kitchen door which was unlocked. The DON shared that NA #2 observed that the interior kitchen door was unlocked because the door latch had been unlocked from the inside.An interview with the Administrator on 7/17/25 at 1:34 PM revealed Nurse #1 texted her at 8:04 PM on 7/11/25 about Resident #1 being found outside the facility. She stated that she got to the facility about 10 to 15 minutes later. The Administrator stated that as soon as she arrived at the facility, she made sure Resident #1 was alright, and he was already back in his room. She said she tried to interview him, but he was staring at the television in his room with his hands behind his head, and he didn't say anything to her after she asked him what he was doing outside the facility. The Administrator further stated that she checked all the doors to make sure they were all locked. She shared that every door was locked except the exterior kitchen door leading to the outside close to the dishwasher, so she locked it back. The Administrator also stated that she texted the Medical Director to notify him about the incident, and she started talking to staff about what to do when someone eloped.The Administrator was informed of immediate jeopardy on 7/17/25 at 11:48 AM.The facility provided the following corrective action plan:Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 07/11/2025 at approximately 8 PM Director of Clinical Services was notified by nurse at the facility that resident had exited the building and was seen walking in the back parking lot. Nurse stated that resident was assisted back into the building by staff without incident. Wheelchair was located in the dining room by the door that leads into the kitchen. Door was closed at this time and secured, requiring key pad to open the door. Director of Clinical Services notified the Administrator along with the [NAME] President of Clinical Services and Regional [NAME] President. On 07/11/2025 the Administrator walked perimeter of building checking all exit doors, all were secure. On 07/11/2025 a complete assessment including a skin assessment was completed by the nurse assigned to resident with no negative findings. Resident's vital signs were within normal limits/baseline, with temperature being 98.4. The temperature outside at this time was between 79-81 degrees. On 07/11/2025 15 minute checks were initiated by the Director of Clinical Services on resident. The Director of Clinical Services provided this instruction to the nurse assigned to resident and it would be on-going until further notice. The 15 minute checks are documented on the monitoring form with the nurses verbally reporting confirmation of the completion of the 15 minute checks for resident shift to shift. On 07/11/2025 the Director of Clinical Services verified using the census from electronic medical record that every resident was accounted for. All residents were present and accounted for. On 07/12/25 the Unit Manager completed an elopement risk evaluation in electronic medical record which was used to update the Elopement Book to include the resident that eloped and any residents at high risk for elopement. The Elopement Book is maintained at the sole nurses station which is behind a secured entrance in which all visitors must be assisted in or out by a facility staff member. On 07/12/2025 the nurse assigned to the resident completed a skin assessment on resident with no negative findings noted.On 07/13/2025 Skin assessment was completed on resident by the Director of Clinical Services, no changes noted. No negative findings noted.On 07/13/2025 the Director of Clinical of services updated the care plan to include exit seeking behaviors. Interventions included: alert/call resident's wife to sit with resident as needed, facility to attempt to look for a more secure facility for resident with responsible party permission, include resident in activities that are ongoing in the facility, and to monitor resident's whereabouts more frequently. Kardex was updated at this time to reflect the current interventions added to the care plan for nursing staff to be aware. Care plan updates and Kardex updates were included in the education that was provided to facility staff. On 07/13/2025 BIMS assessment was completed on resident by the Director of Clinical Services. Previous BIMS was a 3, with current BIMS a 2, thus validating no changes in cognitive ability. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 07/11/2025 once the resident was back inside the building, the Certified Nursing Assistant noted resident's wheelchair sitting at the kitchen door where the lock was manually unlocked and immediately locked the door. Administrator obtained statements from current staff working at time of elopement. After review of statements a root cause was found to be the kitchen door was unlocked and not secured. From 07/11/2025 all exterior doors along with the door leading from the dining room into the kitchen have been checked by the Administrator and/or Maintenance. All doors have been closed and secured.On 07/12/2025 the locking knob for the kitchen door keypad was removed by the Maintenance Director. This removal has made the keypad an automatic locking door. The kitchen staff have the code and must use the keypad each time to open the door. On 07/12/2025 to 07/13/2025 Elopement Risk Assessments were completed on current residents in the facility by the Unit Manager and the Director of Clinical Services. Any residents triggering for elopement risk were updated in the Elopement Book that is placed at the nurses station and their care plans were updated accordingly. Elopement Risk Assessments are completed by the nursing staff upon admission, quarterly and as deemed necessary. Staff are made aware of care plan updates through education. On 07/13/2025 and 07/14/2025 Elopement Drills were conducted on all three shifts by the Administrator and/or Maintenance Personnel. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 07/11/2025 - 07/13/2025 Director of Clinical Services provided education on elopement and ensuring doors are closed and locked to current staff. Education was conducted via text messaging and/or email via scheduling portal immediately. Upon start of staff's next working shift, education was reviewed with staff signing acknowledgment of education and understanding. On 07/13/2025, Administrator and Director of Clinical Services continued to provide one on one education and answered any questions to nursing department, therapy department, dietary department, housekeeping department, and management team with validation of education via question and answer time. Education focused on residents at high risk for elopement (Elopement Book which is located at the nurses station), what to do in the event of a missing resident, and when to notify Director of Clinical Services and Administrator. Effectiveness of education will be measured by conduction of elopement drills one time per week for 4 weeks alternating between shifts, then monthly thereafter for 2 months to ensure understanding of elopement procedure. The Executive Director will bring the results of the elopement drills to the Quality Assurance Performance Improvement meetings.On 07/12/2025 Dietary staff were provided education by the Administrator pertaining to making sure that kitchen is secure upon leaving at night and that the door from the kitchen to the dining room is not propped open. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.On 07/13/2025 the Administrator held an Ad Hoc Quality Assurance Performance Improvement with the Medical Director and Director of Clinical Services to approve the plan.Starting on 07/14/2025 Maintenance and/ or designee to complete audits 2 times/day 7 days/week at random times for 4 weeks then daily for 4 weeks to ensure that all exterior doors are secure and the door leading from the dining room into the kitchen is closed. Immediate action to be taken for any positive findings. The Director of Clinical Services will bring results of these audits before the Quality Assurance and Performance Improvement Committee monthly with the QAPI Committee responsible for ongoing compliance. In the monthly Quality Assurance and Performance Improvement Meeting, the Interdisciplinary Team will review all elopements to ensure appropriate interventions are in place and care plan updated x8 weeksQAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing.Alleged date of IJ removal date: 7/15/2025 Validation of the facility's corrective action plan was conducted on 7/17/24 through record review and staff interviews. A review of the 15-minute check sheets indicated Resident #1 was monitored every 15 minutes by staff from 7/11/25 at 8:00 PM to 7/15/25 at 8:00 PM. The Elopement Book included residents at high risk for elopement, and it was maintained at the nurses' station. A review of the Elopement Drill sign-in sheets indicated elopement drills were conducted on 7/13/25 at 2:19 PM and 7/14/25 at 5:16 AM to cover staff on all three shifts. A review of the facility's monitoring audits conducted on 7/14/25 through 7/16/25 indicated all outside doors were locked and secured, including the door leading from the dining room to the kitchen, and all door alarms were active. Interviews were conducted with nursing, therapy, dietary, and housekeeping staff which indicated they received education on the facility's elopement policy and ensuring doors were closed and locked. The staff revealed the education included residents at high risk for elopement, what to do in the event of a missing resident, and when to notify the DON and the Administrator. Interviews with dietary staff revealed they received education related to making sure that the kitchen was secure upon leaving at night and that the door from the kitchen to the dining room was not propped open.The corrective action plan completion date and IJ removal date of 7/15/25 was validated.

Based on record review, observations and interviews with staff and the Medical Director, the facility failed to maintain a medication error rate of less than 5% as evidenced by the administration of a wrong dosage and failure to have the resident rinse their mouth after being given a steroid inhaler (2 medication errors out of 31 opportunities), resulting in a medication error rate of 6.45% for 2 of 4 residents observed during medication pass (Resident #2 and Resident #3).The findings included:1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included vitamin D deficiency.The Physician's Orders in Resident #2's electronic medical record indicated an active order dated 7/1/20 for Vitamin D3 tablet 25 micrograms (1000 units) (Cholecalciferol) - give 1 tablet by mouth one time a day related to vitamin D deficiency.On 7/16/25 at 9:19 AM, Nurse #2 was observed as he prepared and administered Resident #2's medications. Nurse #2 administered one tablet of Vitamin D 10 micrograms (400 units) to Resident #2.A phone interview with Nurse #2 on 7/17/25 at 10:03 AM revealed he didn't notice the formulation or label on the Vitamin D bottle before he administered the medication to Resident #2. Nurse #2 stated that he should slow down and look at the medication label to make sure the dosage was accurate.An interview with the Unit Manager (UM) and observation of the medication cart on 7/17/25 at 2:31 PM revealed Vitamin D was only available in the 10-microgram formulation. The UM stated he wasn't sure about the other medication carts, but Nurse #2 could have given Resident #2 two and half tablets from the Vitamin D bottle for the correct dose.An interview with the Director of Nursing on 7/16/25 at 4:22 PM revealed the nurse should have given the correct dose of Vitamin D to Resident #2. 2. Resident #3 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD).The Physician's Orders in Resident #3's electronic medical record indicated an active order dated 3/22/25 for Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 micrograms/actuation (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally one time a day for COPD. A review of the manufacturer's recommendations indicated to rinse mouth with water after taking a dose of the medicine and spit the water out. Do not swallow the water. This is important to prevent the development of oral thrush, a fungal infection that can occur due to the presence of corticosteroids in the inhaler. On 7/16/25 at 9:27 AM, Nurse #2 was observed as he administered Resident #3's medications. Nurse #2 activated Resident #3's Trelegy inhaler and handed it to Resident #3 who took a deep breath while inhaling into the inhaler. Resident #3 handed the inhaler back to Nurse #2 who handed Resident #3 her other medications. Resident #3 swallowed her pill medications and took a sip of water through a straw.An interview with Nurse #2 on 7/16/25 at 9:49 AM revealed he had thought about instructing Resident #3 to rinse her mouth after he gave her the inhaler, but it was too late because she had already reached for her pills. Nurse #2 stated that he should have asked her to rinse her mouth and spit the water out.A phone interview with the Medical Director on 7/17/25 at 9:37 AM revealed it was part of the facility's policy that the nurses were supposed to have the residents rinse their mouths and spit out the water after giving them a Trelegy inhaler. The Medical Director stated that the reason for this was that the effects of the medication could stay in the oral mucosa and cause irritation.An interview with the Director of Nursing on 7/16/25 at 4:22 PM revealed the nurse should have instructed Resident #3 to rinse her mouth and spit the water out after the administration of the inhaler.

Based on record review and interviews with the resident's responsible party and staff, the facility failed to notify the responsible party of elopement for 1 of 3 residents reviewed for notification of change (Resident # 1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia.The significant change in status Minimum Data Set assessment dated [DATE] indicated Resident #1 was severely cognitively impaired.A review of Resident #1's medical record indicated a late entry nursing progress note dated 7/12/25 at 3:29 PM by Nurse #1 which read, in part: Nurse Aide (NA) #1 and NA #2 witnessed Resident #1 outside, walking past the C hall door at approximately 7:45 PM. NA #1 immediately ran outside to assist him back into the building while NA #2 came and alerted Nurse #1. Nurse #1 assisted NA #1 with guiding Resident #1 back into the building via C hall door. NA #2 went to find Resident #1's wheelchair, finding it in the dining room just outside the door going into the kitchen. Once Resident #1 was assessed, Nurse #1 checked the doors and found all doors to be closed and locked. When NA #2 checked the kitchen door, she found it to be unlocked. Apparently, Resident #1 went through the unlocked kitchen door and outside through the back door of the kitchen. Nurse #1 notified the Director of Nursing as well as the Administrator who came to the facility shortly thereafter. An interview with Resident #1's responsible party (RP) on 7/16/25 at 11:01 AM revealed Resident #1 had gotten out of the facility on the evening of 7/11/25 around 8:00 PM. Resident #1's RP stated that from what was reported to her, Resident #1 had wheeled himself into the dining room, opened the door to the kitchen, which was left unlocked, and went outside through another door inside the kitchen. Resident #1's RP stated that she didn't find out about the incident until the next day, and it had upset her. She further stated that a resident first told her about Resident #1 getting outside the facility as she was walking up the sidewalk towards the facility on 7/12/25. The RP also stated that the nurse who was supposed to call her on the evening of 7/11/25 had called her since and apologized to her.A phone interview with Nurse #1 on 7/18/25 at 7:50 PM revealed she had thought the Administrator was going to call Resident #1's RP on the evening of 7/11/25. Nurse #1 stated that she knew it was her responsibility to notify Resident #1's RP about the incident, but she had gotten behind, had tried to get her medication pass started, and had forgotten about calling his RP that night. Nurse #1 further stated she called Resident #1's RP on 7/14/25 to apologize.An interview with the Unit Manager (UM) on 7/16/25 at 2:22 PM revealed whenever Nurse #1 did the assessment on Resident #1 after he was brought back inside the facility, he had assumed that she had taken the responsibility of notifying his RP. The UM stated that she heard Nurse #1 talking on the phone, and he thought she was calling his RP. The UM also shared that he worked day shift on 7/12/25, and he found out that Resident #1's RP was not called from the night before, but he knew Nurse #1 called her later to apologize.An interview with the Director of Nursing (DON) on 7/17/25 at 11:04 AM revealed that attempts were made to call Resident #1's RP on the evening of 7/11/25, but the phone number they had in his medical record was not correct. The DON stated that the RP was told about the incident on 7/12/25 when she came into the facility.A follow-up interview with Resident #1's RP on 7/17/25 at 11:15 AM revealed the Administrator told her that they called the phone number listed in Resident #1's medical record and it was inaccurate. The RP stated she looked at Resident #1's medical record and they had two phone numbers listed, but one of them was correct. She asked them why they didn't call both numbers listed but she didn't get a clear answer. She stated that Nurse #1 had called her at 6:30 AM on 7/14/25 to tell her that it was her responsibility to call her on the evening of 7/11/25 and she didn't, and she apologized.An interview with the Administrator on 7/17/25 at 1:34 PM revealed she did not call Resident #1's RP to notify her about the elopement because she thought Nurse #1 would call her as it was part of the incident report. The Administrator stated that there were two phone numbers listed in Resident #1's medical record, but one of them was correct, and that the nurse should have called both numbers to try to get in touch with Resident #1's RP.

Based on observations, record review, and staff interviews, the facility failed to protect a resident's right to be free from abuse when Resident #4 attacked Resident #5 which resulted in cuts above the right eye, bruising around the nose, and bleeding from his gums and required an emergency room visit. This was for 1 of 3 residents reviewed for resident-to-resident abuse (Resident #4). The findings included:Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, and major depressive disorder.Review of Resident #4's care plan, last revised on 03/31/25 revealed no care plan areas for aggressive behaviors.Review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed he was severely cognitively impaired with no delusions, behaviors, rejection of care, or instances of wandering. Resident #4 was independent with mobility and was able to ambulate on his own.Resident #5 was admitted to the facility on [DATE] with diagnoses of dementia without behaviors, unspecified mood disorder, psychosis, stroke, muscle weakness and atrophy, and need for assistance with personal hygiene.Review of Resident #5's most recent quarterly Minimum Data Set assessment dated [DATE] revealed he was severely impaired with no delusions, behaviors, rejection of care, or instances of wandering. Resident #5 was coded as dependent on others for the completion of his Activities of Daily Living (ADL).Review of the facility's Reportable Incidents revealed an incident dated 07/08/25. Review of the facility's investigation revealed Resident #4 was observed with one hand near the throat of another resident (Resident #5) and tried putting a hair comb in Resident #5's mouth with the other. Per the investigation report, Resident #4 and Resident #5 were separated by nurse aides (NA) NA #4, NA #5 and NA #6 and assessed by the nurse (Nurse #3). Resident #5 was observed to have cuts above his right eye and was bruised around his nose. There were no noted injuries to Resident #4. The investigation reported that both residents were sent to the emergency department for further evaluation and were returned to the facility a few hours later. Per the investigation report, Resident #4 was moved to another room by himself and was placed on one-on-one supervision. The investigation report indicated there was no lingering effects from the altercation with Resident #5 not experiencing fear or feelings of intimidation from Resident #4.An interview with NA #4 via telephone on 07/17/25 at 2:03 PM revealed she was familiar with the altercation and verified that she responded to the event on 07/08/25. NA #4 reported she was at the nurse's station when she heard shouting coming from Resident #4 and Resident #5's room. She reported she ran down the hall and when she entered the room, she observed Resident#4 with one hand on Resident #5's neck and the other hand with a comb and it appeared as though Resident #4 was attempting to put the comb in Resident #5's mouth. She stated she called for more assistance and pulled Resident #4 away from Resident #5. She took Resident #4 into the hallway, left him with NA #5 and went in to check on Resident #5. She reported by this time, NA #6 had arrived, and he went in the room as well to check on Resident #5. She reported she observed several small cuts above Resident #5's right eye, some redness around Resident #5's left eye, and some scant bleeding from Resident #5's gums. She reported Resident #4 was taken by NA #5 and NA #6 up to the nurse's station and reported the incident to Nurse #4. She stated Nurse #4 assessed both residents and notified administration and the Director of Nursing arrived at the facility in about 20 minutes. She reported both residents ended up being sent out to the emergency department. NA #4 stated that prior to the altercation, Resident #4 had a quiet evening with no noted agitation or aggression. She reported when she asked Resident #4 why he had attacked Resident #5, all he would say was he was calling me out all night. NA #4 reported, to her knowledge, there had been no previous incidents between Resident #4 and Resident #5. An interview via telephone with NA #5 on 07/17/25 at 9:18 AM revealed she was one of the staff who responded to the altercation. She reported she was at the nurse's station when she heard yelling. She reported when she entered the room, Resident #4 was standing over Resident #5 with one hand on Resident #5's neck and he was using the other hand to put a comb in Resident #5's mouth. She reported Resident #4 was separated from Resident #5 and was taken to the hallway. She stated it appeared as though Resident #5 had cuts above his right eye, had redness on his cheek and appeared to have some cuts on his gums. She stated she overheard Resident #5 asking why did he do that? Resident #4 was taken down the hall to the nurse's station and was asked why he attacked Resident #5, and he would only respond with he was asking for it and would not say anything else. NA #5 reported administration was called, and both residents ultimately were sent to the emergency department for further evaluation.An interview via telephone with NA #6 on 07/17/25 at 11:28 AM revealed he was clocking out from his shift when he heard a commotion and heard NA #4 calling for assistance. He reported when he got to the room, NA #4 and NA #5 were already there and both residents had been separated. Stated he observed Resident #5 to have redness around his eyes and appeared to be bleeding from his gums. He reported he assisted Resident #5 in getting into a wheelchair and Nurse #4 had come to the room. He reported Nurse #4 assessed both residents and Resident #4 was taken to the nurses' station. NA #6 stated administration was called and both residents were sent to the emergency room. NA #6 reported that Resident #4 had seemed to be at his baseline that night and reported he had not been made aware of any aggressive behaviors prior to this incident. Multiple attempts to reach Nurse #4 via telephone calls were unsuccessful.Review of a skin assessment for Resident #4 dated 07/08/25 at 10:00 AM revealed the following: No injuries noted, denies pain, no mental distress noted.Review of a skin assessment for Resident #5 dated 07/08/25 at 11:00 AM revealed the following: mild swelling to right eye/under eye, along cheek bone, scratch to right side of nose. Denies pain, denies any needs, no mental distress or anguish noted.Review of Resident #5's emergency room provider notes revealed he was seen on 07/08/25 and was treated for cuts above his right eye and returned to the facility the same day.An interview with Resident #5 on 07/17/25 at 8:26 AM revealed he had no recollection of the altercation, had no knowledge of Resident #5 and reported no residents or staff members had ever harmed or assaulted him.Multiple attempts to interview Resident #4 throughout the investigation were unsuccessful. When he was approached in his room, he turned his head away, closed his eyes, and became nonresponsive.An interview with the Director of Nursing on 07/17/25 at 10:54 AM revealed she was aware of the incident between Resident #4 and Resident #5. She reported Resident #4 had a previous altercation with another roommate several weeks prior and they had moved Resident #4's roommate to another room. She reported after that incident, the facility started looking at all the residents and roommate compatibility. She reported during this time, they felt that Resident #4 and Resident #5 would be compatible roommates as Resident #5 was a quieter resident and both gentlemen liked the room warm. She reported she was unsure how long Resident #4 and Resident #5 were roommates but reported it had not been a long time. She stated on 07/08/25 she was contacted around 3:45 AM about an altercation between Resident #4 and Resident #5. She reported she was informed that NA #4, NA #5, and NA #6 had gone into the residents' room and observed Resident #4 trying to shove a comb into Resident #5's mouth. The Director of Nursing stated she informed the staff to keep the men separated and to put Resident #4 on one-to-one supervision. She reported Nurse #4 advised that both men should be sent to the emergency department for further evaluation, so they received the order from the on-call physician and both men were sent. She continued, stating when both residents returned from the emergency department, Resident #5 had some minor swelling under his right eye but no other apparent injuries. She reported Resident #4 and Resident #5 were closely observed the rest of the day and reported by the end of the day, the swelling to Resident #5's eye had subsided. She reported Resident #4 continued on one-to-one supervision and was moved to an empty hall in a private room. The Director of Nursing stated that when both men returned from the emergency department, she completed a full body skin assessment on both residents. An interview with the Administrator on 07/17/25 at 1:18 PM revealed she was aware of the altercation between Resident #4 and Resident #5. She stated several weeks prior to that incident, Resident #4 had gotten into another altercation with another resident, who was his roommate at the time. She reported after the initial altercation by Resident #4, the administrative team discussed roommate compatibility and felt that Resident #4 and Resident #5 would have been a good fit to room together. She reported when they moved Resident #5 into the room with Resident #4, they had no initial concerns about them rooming together. She reported it was reported to her that Resident #5 was observed trying to shove a comb into Resident #5's mouth. She reported that both residents were separated, and the Director of Nursing was called. She reported she was notified by the Director of Nursing of the altercation. The Administrator reported that both men were sent to the emergency department for further evaluation. She stated when Resident #4 and Resident #5 returned from the emergency department, both residents were moved to new rooms, with Resident #4 being moved to an empty hall, in a room by himself, and was placed on one-to -one supervision for about a week. She stated when she went to speak with each resident, neither resident could recall the altercation in detail. The Administrator indicated she could not recall what injuries Resident #5 sustained because of the altercation.The facility provided the following corrective action plan with a compliance date of 07/12/25.1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 07/08/2025 at 3:45 AM Director of Clinical Services was notified of allegations of resident to resident abuse involving residents listed above. Staff report that Resident #4 had some skin tears and swelling to his eyes/nose area. Resident #5 without injuries. Residents were immediately separated with Resident #5 being placed on 1:1 supervision. Both residents were sent to the ER per on call provider. Director of Clinical Services notified Administrator. On 07/08/2025, Initial reportable was filed; [NAME] Police Department and Adult Protective Services (APS) were notified by the Administrator.On 07/08/2025, Medical Director was notified by the Director of Clinical Services.On 07/08/2025 Skin assessments were completed on residents listed above by the Director of Clinical Services. Resident #4 mild swelling noted under right eye and scratch noted along right side of nose. Resident is talkative and pleasant; denies pain at this time. No signs of mental distress noted. Resident #5 no negative findings noted. Resident denies pain at this time. No signs of mental distress noted. Resident is talkative per his normal behavior. 07/08/2025, Resident #4 was placed in a private room with 1:1 supervision by Certified Nursing Assistants. 07/08/2025 Care Plans were reviewed on both residents with updates being made as warranted by the MDS Nurse. 07/09/2025 Nurse Practitioner with psychiatric services notified of incident by the Director of Clinical Services . States that he will be in later today. Resident #5 is pending consents, Nurse Practitioner made recommendations to facility Nurse Practitioner. Depakote (an antiepileptic medication that can be used to treat bipolar disorder) was added. 07/10/2025 Follow up assessments completed on both residents by Director of Clinical Services with no changes noted from previous assessments. Resident #4 continues to deny pain, no signs of mental distress noted. 2 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 07/08/2025 Skin Assessments were completed by the Director of Clinical Services for all residents with a BIMS (Brief Interview for Mental Status) of 9 and below. No negative findings were noted. On 07/08/2025 Resident interviews were completed by the Director of Social Services for all residents with a BIMS of 10 and above. As part of the resident interviews, roommate compatibility questions were also looked at. No negative findings were noted.On 07/08/2025, Director of Clinical Services and the Administrator reviewed incident log for the past 30 days looking for trends in resident and resident incidents. At this time it was noted that Resident #5, does not do well with a room mate and at this time would be better suited to remain in a private room.A3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 07/08/2025 to 07/11/2025 Staff were provided education on abuse, neglect and misappropriation based on the facility's policy by the Director of Clinical Services and the Administrator. Education was provided in person and via the telephone for staff that were not working during these dates by the Director of Clinical Services. Education focused on staff intervening early on during situations or conflicts that could potentially escalate along with notifying the Director of Clinical Services and/or Director of Social Services of all roommate incompatibility issues. At the time of education, there was a period for questions and answers to review information provided. I4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Ad Hoc Quality Assurance and Performance Meeting held on 07/12/2025 with the Administrator, Director of Clinical Services and Medical Director to accept and approve of the plan. Director of Nursing/ or designee to complete random audits weekly of 5 residents with a BIMS of 10 and higher, to inquire about abuse while also looking at roommate compatibility. Immediate action to be taken for any positive findings. The Director of Nursing Services will bring results of these audits/interviews before the Quality Assurance and Performance Improvement Committee monthly with the QAPI Committee responsible for ongoing compliance. In the monthly Quality Assurance and Performance Improvement Meeting, the Interdisciplinary Team will review all allegations of abuse to ensure appropriate interventions are in place and care plan updated x8 weeks. QAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing. Compliance date: 07/13/2025The corrective action plan was validated on 07/17/25. Review of the facility provided monitoring tools revealed the facility had ongoing monitoring to ensure that no residents were subject to acts of abuse from any source. There was evidence of in-services with sign-in sheets, audits, and other interventions that were mentioned in the corrective action plan. Interviews with staff revealed they were able to verbalize the education regarding abuse policies and procedures. The staff interviewed were able to verbalize the steps needed to take in the event that they observed aggressive behaviors and concerns regarding the compatibility of roommates. The interviewed staff also were able to verbalize the steps they should take if they observe an altercation between residents. The completion date of 07/13/25 was validated.

Based on record review, and resident, staff, and detective interviews, the facility failed to protect the resident's (Resident #70) right to be free from misappropriation of property when Housekeeper #1 used Resident #70's debit card to set up a mobile payment application account on his [Housekeeper #1's] phone without Resident #70's permission or knowledge. Housekeeper #1 was alleged to have sent approximately $4,000.00 of unauthorized payments from Resident #70's bank account to his mobile payment application account from February 2024 to May 2024. Resident #70 stated, I am poor and he took everything I had. He indicated he was very upset that someone he trusted had taken advantage of him and he was worried to death over the loss of money and the potential for identity theft. This deficient practice occurred for 1 of 3 residents (Resident #70) reviewed for abuse, neglect, and misappropriation of resident property. The findings included: Resident #70 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #70 was cognitively intact. A review of the facility's reportable incidents revealed an initial allegation report dated 5/30/24 indicating the facility became aware on 5/29/24 that money was transferred from Resident #70's bank account to a former employee's (Housekeeper #1) mobile payment application account. The report indicated there was reasonable suspicion of a crime, and the alleged misappropriation of resident property was reported to law enforcement on 5/30/24. A review of Resident #70's bank account records from January 2024 to May 2024 revealed there were transactions of sending money from Resident #70's bank account to mobile payment application accounts starting on 2/05/24 along with overdraft fees charged by the bank. There were five transactions on 2/05/24, each sending $10.00 to Housekeeper #1's mobile payment application account. Transactions sending money from Resident #70's bank account to various mobile payment application accounts, including Housekeeper #1's, continued to recur several times a day from 2/5/24 through 5/6/24 in amounts ranging from $5.00 to $60.00. The transactions made to mobile payment application accounts and the bank overdraft charges totaled approximately $4,000.00. A review of the police department incident report indicated a report was filed on 5/10/24 at 11:11 AM concerning Resident #70 and stolen money from his bank account. An interview with Resident #70 was conducted on 12/20/24 at 11:27 AM. Resident #70 stated he was very sick and had not been able to use his debit card or monitor his bank account after his admission to the facility. Resident #70 revealed he did not recall the date, but a week or 2 after he was admitted to the facility, he asked Housekeeper #1 if he would purchase him a drink from the facility's vending machine. He indicated he gave Housekeeper #1 his debit card, he purchased the drink and then returned his debit card. Resident #70 revealed that was the only time he recalled Housekeeper #1 having possession of his debit card. He revealed a few months later the Business Office Manager (BOM) came to see him to discuss paying his bill. Resident #70 indicated he realized his debit card was missing and he asked the BOM to assist him with calling the bank to request a new card. He stated when they called the bank, he was informed that his account had been overdrawn for several months due to debit transactions that were made to a mobile payment application account. Resident #70 revealed he never had an account with a mobile payment application, and the only time his debit card was used after his admission to the facility was when Housekeeper #1 purchased him a drink from the vending machine. He further revealed he was not aware of any other staff members having possession of his debit card which indicated to him Housekeeper #1 was responsible for taking his money. Resident #70 stated, I am poor and he took everything I had. He indicated he was very upset that someone he trusted had taken advantage of him and he was worried to death over the loss of money and the potential for identity theft. Resident #70 indicated that he was interviewed by the police and wanted to press charges against Housekeeper #1, but there was not enough evidence to charge him, and the case was closed. An interview with the BOM on 12/11/24 at 11:37 AM indicated she did not recall the date but at the end of April she met with Resident #70 to discuss payment of his monthly bill, and he told her he lost his debit card and needed assistance contacting the bank. She revealed they called the bank a few days later and were informed that Resident #70's account had been overdrawn since January and there were several transactions of sending money to a mobile payment application account. She indicated that Resident #70 did not know what a mobile payment application was and had never set up an account. The BOM stated she obtained Resident #70's bank account records with is his permission from January 2024 to May 2024 and reviewed them on 5/10/24. She revealed there were several transactions sending money to various mobile payment application accounts, one of which was Housekeeper #1's. The BOM stated she contacted the mobile payment application company, and they informed her Housekeeper #1 had opened an account linked to Resident #70's debit card. She stated she immediately notified the Former Administrator of the concern, and he called the police. The BOM indicated the police assigned a detective to the case and an investigation was completed but no charges were filed. She revealed when the detective requested records from the mobile application company, he was told they had no record of Housekeeper #1's account. She stated she worked with the bank and tried to get them to credit the money Resident #70 lost but they would only go back 60 days from the date they became aware of the fraudulent activity. She indicated that Resident #70 agreed to set up a trust account managed by the facility and his social security check began to directly deposit into the account in June. The BOM revealed that Resident #70 had an outstanding bill with the facility that she planned to write off. An attempt was made to call Housekeeper #1 on 12/11/24 at 3:36 PM and the number was no longer in service. A phone interview was conducted with the Former Administrator on 12/12/24 at 8:59 AM. He stated the BOM notified him on 5/10/24 that she reviewed Resident #70's bank account transaction records and identified concerns related to mobile payment application withdrawals made by Housekeeper #1. He revealed that Housekeeper #1 was no longer employed at the facility when the concern was identified. He indicated he filed a police report on 5/10/24. He indicated that the police assigned a detective to the case, and records were requested from the mobile payment application company, however they informed the police they had no records of Housekeeper #1's account. He stated the detective informed him on 5/30/24 that Resident #70's bank account records did not provide enough evidence to file charges against Housekeeper #1, and they would be closing the case. A phone interview conducted with the Detective on 12/16/24 at 9:11 AM indicated the facility filed a police report on 5/10/24 related to Housekeeper #1 setting up a mobile payment application account linked to Resident #70's debit card without his knowledge or permission. He stated the facility provided Resident #70's bank account records which he reviewed and determined there was enough evidence to open a case. He indicated he obtained a search warrant requesting the mobile payment application company release the records of Housekeeper #1's account, however they informed him there was no record of the account. The Detective revealed that without records from Housekeeper #1's mobile payment application account there was not sufficient evidence to file charges and the case was closed. The Administrator was notified of immediate jeopardy on 12/11/24 at 10:52 AM. The facility provided the following corrective action plan: Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 05/10/2024, the Business Office Manager obtained bank statements for Resident #70 and identified on the bank statements that Housekeeper #1 transferred no more than $3,963.15 through a money transfer application from Resident #70's bank account to Housekeeper #1's phone application between 02/05/2024 - 04/08/2024. Housekeeper #1 no longer worked at the facility effective 03/07/2024. The facility recognized that residents who manage their own personal funds have the potential to be affected by the noncompliance of misappropriation of resident property. On 05/13/2024, the Business Office Manager, with consent from Resident #70, requested a direct deposit for Resident #70's Social Security checks into his RFMS (Resident Fund Management System) account. Beginning on 06/03/2024 Resident #70's Social Security checks were direct deposited into his resident trust account managed by the facility. RFMS is a complete resident fund accounting system for handling resident funds, to provide banking solutions, such as direct deposit and direct debits. The Executive Director reported the misappropriation of Resident #70's property to local law enforcement on 05/10/2024. The Executive Director filed the initial allegation to the State agency on 05/30/24. On 05/24/2024, Resident #70 was seen by the psychiatric nurse practitioner, the progress note indicated Resident #70 denied feeling depressed, anxious, and stated Resident #70 left his room to socialize with others. He continued to be followed by psychiatric services. Resident #70's liability from June 2024 through December 2024 with a total balance of $628 has been written off without any penalty to the resident. The decision was made by the Regional Business Office Manager to write off the balance on 5/21/2024. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: The Business Office Manager audited the current Resident Financial Management System (RFMS) on 05/15/2024 to ensure no unauthorized activity had occurred. No discrepancies or suspicious activity were identified. Also, during this time no concerns were noted by any other residents/responsible parties regarding unauthorized activity with their personal banking accounts. No other residents/responsible parties reached out to the business office for additional assistance with their personal banking accounts. The Business Office Manager reconciled the asset account (bank account and register statement balance) to the resident trust fund liability account (balance of residents account in the RFMS) to verify the accounts monthly. All disbursements made from the Resident Trust Fund must be documented with a properly signed withdrawal ticket. The facility maintains a pre-numbered withdrawal book with withdrawal tickets in a triplicate to record the disbursements made from the Resident Trust account. A Resident Trust fund statement is mailed to the patient and or Guardian/Responsible Party quarterly. The statement included all accounting transactions to include debits and credit. This process pertains to interviewable and non-interviewable residents with RFMS accounts. On 05/30/2024, the Social Worker interviewed alert and oriented residents to ensure no employee had asked any resident for money or use of their debit, credit, EBT (food stamps) and or Ucard (United Healthcare debit card). No issues or concerns identified. The RFMS reconciliation process was utilized for the non-interviewable residents. Staff were interviewed regarding misappropriation of resident property by the Executive Director and/or Director of Nursing on 05/30/2024. No concerns identified. Address the measures put into place or systemic changes made to ensure that the deficient practice will not occur: The Executive Director and/or Director of Nursing re-educated current staff including contracted staff with validation of understanding on the Abuse Policy with emphasis on misappropriation of resident property, unauthorized use of a resident's debit, credit, EBT and or UCard for personal use or gain on 05/30/2024 - 06/05/2024. Education also included the use of a sign out sheet for snacks and drinks purchases. The form included date, name, items purchased, amount given by the resident to the staff, amount returned to the resident, staff signature, resident signature, and a place to have two staff sign if the resident is unable to sign. The snacks and drinks form is located at the nursing station and is reviewed weekly by the Director of Nursing for accuracy to ensure the amount of money given by the resident to the staff minus the item purchased equals the amount of money returned to the resident. Newly hired staff will be educated in orientation. Staff were educated to not accept debit cards from residents for vending machine purchases on 06/05/2024. The Executive Director verbally educated Residents educated the use of debit cards by staff is not allowed for vending machine purchases on 06/05/2024 via room to room. Residents are made aware upon admission and throughout their stay of having the option to secure valuables. The Maintenance Director handled the request of a resident's need for a lock on their nightstand. A key is provided by the Maintenance Director and/or Executive Director. In the event the nightstand does not have locking capabilities, the Maintenance Director will install a lock and provide the key to unlock the nightstand to the resident and the spare key is in a locked box / drawer in the Maintenance Directors office. All residents/responsible parties were offered a RMFS account upon admission and can make changes any time during their stay with consent to the business department. Address how the facility will monitor its corrective actions to ensure the deficient practice will not recur: On 06/05/2024, the Executive Director held an ADHOC Quality Assurance Performance Improvement meeting. The Executive Director presented the deficient practice of misappropriation of resident property and implemented a plan of action to include quality improvement monitoring and the frequency of monitoring. The Executive Director and/or Director of Nursing to complete quality monitoring of five residents weekly for twelve weeks to ensure residents are protected from misappropriation of personal property. Questions asked of the 5 residents included in the quality monitoring are Do you have any concerns related to your finances to include your debit card, EBT card and/or U card? and Do you know who to report concerns to?. The Business Office Manager reconciled the asset account (bank account and register statement balance) to the resident trust fund liability account (balance of residents account in the RFMS) to verify the accounts monthly. All disbursements made from the Resident Trust Fund must be documented with a properly signed withdrawal ticket. The facility maintains a pre-numbered withdrawal book with withdrawal tickets in a triplicate to record the disbursements made from the Resident Trust account. A Resident Trust fund is mailed to patient and or Guardian/ Responsible Party quarterly. The statement includes all accounting transactions to include debits and credit. This process pertains to interviewable and non-interviewable residents. Members of the Quality Assurance Performance Improvement committee include Executive Director, Medical Director, Director of Nursing, the Manager of Social Services, the Housekeeping Manager, the Business Office Manager, the Human Resources Coordinator, Medical Records Clerk, Central Supply Clerk, Admissions Director, Nurse Managers, Dietary Manager, and the Environmental Services Director. The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting monthly to ensure ongoing compliance for 3 months. Quality Improvement monitoring schedule will be modified based on findings of monitoring. The Executive Director is responsible for overseeing the plan of correction. The center Executive Director alleges compliance 06/06/2024. Alleged date of IJ removal: 06/06/24. Validation of the facility's corrective action plan was conducted 12/17/24 through record review and staff interviews. A review of the resident trust account audits indicated they were completed by the Business Office Manager on 5/15/24 and no concerns or discrepancies were identified. An interview conducted with the BOM revealed she continues to audit and reconcile the resident trust accounts monthly and there have been no discrepancies identified. A review of the facility's monitoring audits conducted 6/6/24 through 8/20/24 revealed 5 alert and oriented residents were interviewed weekly and voiced no concerns related to their finances, misappropriation of their personal property or unauthorized charges on their personal bank accounts. Interviews were conducted with housekeeping, nursing, therapy and dietary staff which indicated they received education on the facility's abuse and reporting policy including misappropriation of resident property. The staff revealed the education also included the procedure to follow if a resident requests assistance with purchasing a snack or drink, which included only using cash (no payment cards), documenting the amount of cash the resident gave them, the item purchased, and the amount of cash returned to the resident. The corrective action plan completion date and IJ removal date of 6/06/24 was validated.

Based on observation, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 2 of 2 residents reviewed for bladder continence (Resident #74 and Resident #35). Findings included: 1. Resident #74 was admitted to the facility on [DATE] with diagnoses including a stage 4 pressure ulcer to the sacrum. A review of Resident #74's physician orders showed an order dated 10/21/2024 for a 16 French (FR) foley catheter with a 10 milliliter (ml) balloon due to stage 4 sacral pressure ulcer. A review of Resident #74's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was marked as having an indwelling catheter in place but was always incontinent of bladder. An interview was completed on 12/12/2024 at 9:00 AM with the MDS Coordinator. During the interview the MDS Coordinator reported if a resident's MDS assessment was marked for an indwelling catheter then the continence needed to be marked as Not Rated. The MDS Coordinator explained Resident #74's MDS assessment should have been marked as Not Rated, instead of Always Incontinent for incontinence because he had an indwelling catheter. The MDS Coordinator also said the answers in the MDS assessments were system generated, and normally she would [NAME] check those answers but somehow missed it. During an interview on 12/12/2024 at 12:59 PM with the Director of Nursing (DON) she said she expected to see accurate coding on all MDS assessments. An interview was completed on 12/12/2024 at 2:40 PM with the Administrator where she said she expected to see all MDS assessments completed accurately. 38515 2. Resident #35 was admitted to the facility on [DATE] with diagnoses that included paraplegia, and neuromuscular dysfunction of bladder. A review of Resident #35's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her to be cognitively intact and having an indwelling catheter and she was always continent of bladder. A review of Resident #35's treatment administration record indicated she received indwelling catheter care every shift during the lookback period for the assessment. During an interview with Resident #35 on 12/11/24 at 4:46 PM, she reported she had the catheter since before her admission to the facility. Resident #35 stated she had not had the catheter removed, even temporarily, since it was placed. An interview with MDS Nurse #1 on 12/12/24 at 9:00 AM, she stated she had worked as the facility's MDS nurse since April of 2024. She reported Resident #35 had a catheter the entire time she had worked at the facility and that if a resident had a catheter for the entirety of the lookback period of a MDS assessment, then their bladder continence should be coded as not rated. She went on to say the answers in the assessment system were typically automatically generated and she attempted to double check the answers. MDS Nurse #1 stated she thought she had changed Resident #35's continence to not rated but must have missed it. An interview with the Director of Nursing on 12/12/24 at 2:04 PM revealed to her knowledge, Resident #35 had never had her catheter removed and that her bladder continence should have been coded as not rated. She also indicated she expected MDS assessments to accurately reflect the resident, their care needs, and their conditions.

Based on record review, and resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident for 1 of 5 residents reviewed for unnecessary medications (Resident #80). The findings included: Resident #80 was readmitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, neuropathy, and necrotizing fasciitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #80 was cognitively intact and was marked as receiving routine and as needed pain medication. Review of a progress note written by Nurse #2 dated 12/8/2024 at 6:05 pm indicated Resident #80 was administered Baclofen (muscle relaxer) 10 milligram (mg) and Norco (pain reliever) 5/325 mg. Further review of the progress note revealed the on-call provider was notified and Nurse #2 was instructed to monitor the resident's level of consciousness, breathing, and cognition. A review of an additional progress note written by Nurse #2 dated12/8/2024 at 6:43 pm revealed Resident #80 had been notified by Nurse #2 of receiving the wrong medication and he responded, I did not even notice a difference. A telephone interview was completed on 12/10/2024 at 2:05 PM with Nurse #2. During the interview Nurse #2 explained during her medication pass on 12/8/2024 she was putting medications into a medication cup for who she thought was Resident #80. Nurse #2 went on to say there was another resident sitting in his wheelchair behind her yelling while she was putting the medication in the medication cup, and she was distracted by it. Nurse # 2 said she administered the medications to Resident #80 and shortly afterwards she realized she had given Resident #80 the wrong medications. She stated the medications she had given to Resident #80 were Norco 5/325 mg and Baclofen 10 mg and were prescribed for Resident #59. Nurse #2 reported she informed Resident #80 that he received the wrong medications and took his vital signs before calling the on-call provider because she knew she would need to know the resident's vital signs before calling. Nurse #2 said she was told by the on-call provider to monitor Resident #80 for any change in level of consciousness (LOC) and breathing and call back if anything changed. Nurse #2 stated the Director of Nursing (DON) was also notified. Review of Resident #80's current physician orders dated December 2024 revealed Resident #80 was ordered the following medications; Acetaminophen 325 mg (milligrams), give 1 tablet my mouth every 4 hours PRN (as needed) for pain, Roxicodone 5 mg, give 1 tablet my mouth every 4 hours PRN for severe pain with 7-10 pain rating, Gabapentin 600 mg, 1 tablet 3 times a day for neuropathy, and Methocarbamol (a muscle relaxer) 1000 mg, give 1 tablet three times a day for pain. A review of the electronic medication administration record (MAR) for 12/8/2024 showed Resident #80 received Roxicodone 5 mg at 6:32 am and Gabapentin 600 mg was administered three times. A review of Resident #59's MAR for 12/8/2024 revealed he received the medications that were ordered for him which included Baclofen 10 mg and Norco 5/325 mg for pain. Resident #59 reported pain rated at a 2/10. Review of Resident #80's respirations revealed on 12/8/2024 at 6:30 PM his breathes per minute (BPM) were 18 and again on 12/8/2024 at 10:00 PM his BPM were 16. An interview was completed on 12/10/2024 at 1:39 pm with Resident #80. During the interview the resident reported he received medication over the past weekend that was not his. Resident #80 went on to say the medication he received was weak pain medication and it did not really affect him because he was prescribed a stronger pain medication than what he received. Resident #80 reported he did not have any breakthrough pain due to receiving the wrong pain medication. An interview was completed on12/11/24 at 11:36 AM with the DON revealed she was aware of a medication error that occurred on 12/8/2024. The DON explained she was notified by Nurse #2 that she had given Resident #80 a 10 mg Baclofen and a 5/325 mg Norco that was ordered for Resident #59. The DON said Nurse #2 went through all of the necessary steps following the medication administration including making sure Resident #80 was ok by checking his vital signs prior to calling the on-call provider and notifying the on-call provider and herself. The DON reported Resident #59 received his ordered medication. The DON explained neither resident had any complaints about pain and additional education will be provided to Nurse #2 to include Medication Administration involving the 6 rights and how to attempt to limit distractions. On12/10/24 at 4:16 PM a telephone interview was conducted with the Nurse Practitioner (NP). The NP reported she had was notified of a medication error that occurred on 12/8/2024 by Nurse #2 about Resident #80 receiving pain medication and a muscle relaxer that was ordered for Resident #59. The NP stated she instructed Nurse #2 to monitor Resident #80's LOC and breathing and to reach back out if there were any changes. The NP explained she did not see the medication that Resident #80 received as a significant medication error due to the resident having no adverse outcomes and the medications and dosages he received were less than what he was prescribed. An additional interview was conducted on 12/12/2024 at 12:55 PM with the DON where she stated she expected all Nurses to follow the 6 rights of medication administration. The DON also said if a medication error occurred, she expected for the Nurse to notify herself, the provider, and the resident or responsible party. On 12/11/2024 at 2:36 PM an interview was completed with the Medical Director (MD). During the interview the MD reported the difference in medication and dosage that Resident #80 received would not be considered a significant medication error due to Resident #80 did not have any adverse effects related to the medications he received.

Based on record review and staff interviews, the facility failed to update a resident's care plan after she ingested wound cleanser for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #8). The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety, major depressive disorder, and adult failure to thrive. A review of Resident #8's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed her to be severely impaired with no delusions, behaviors, or rejection of care. Resident #8 was coded as having wandering behaviors daily. Resident #8 required supervision with mobility and was coded as using a manual wheelchair. A review of facility incident and accident logs revealed a report dated 03/11/24 that indicated Resident #8 had obtained a bottle of wound cleanser and ingested an unknown amount. Per the incident report, Resident #8 was assessed along with telephone calls made to her representative, the on-call physician, and poison control. The report stated that Resident #8 was placed on observation and with no negative side effects observed. The report also indicated that Resident #8's confused cognition and wandering behaviors contributed to the incident. A review of Resident #8's care plan that was last reviewed on 08/01/24 revealed a care plan for Resident #8 being at risk for wandering behaviors due to dementia. Interventions included to assess for elopement risk, distract Resident #8 from wandering by offering pleasant distractions, and to attempt to identify pattern of wandering and intervene as appropriate. There was no mention of the potential for Resident #8 to attempt to ingest non-food items or any interventions to prevent this from occurring. An interview with MDS Nurse #1 on 12/12/24 at 9:27 AM revealed the MDS nurse was typically responsible for updating care plans that were nursing specific with the Director of Nursing updating care plans when she was not working. MDS Nurse #1 stated she updated care plans anytime there is a change in condition with a resident, which would include changes in behavior. MDS Nurse #1 also stated she had no knowledge of Resident #8 ingesting wound cleanser and reported a behavior like that would be something that should be mentioned in her care plan. She reported she was not working at the facility at the time the incident occurred and provided the contact information for MDS Nurse #2, whom she indicated was the MDS nurse at the time of the incident. MDS Nurse #1 reported she did not know why Resident #8's care plan had not been updated. An interview with MDS Nurse #2 via telephone on 12/12/24 at 11:36 AM revealed she was the MDS Nurse in March of 2024 and reported she was unaware of the incident regarding Resident #8 ingesting wound cleanser. She also reported she did not recall if the interdisciplinary team discussed the incident after it occurred. MDS Nurse #2 reported if she had been made aware of the incident, she would have updated Resident #8's care plan to reflect the potential for Resident #8 to ingest non-food items. MDS Nurse #2 reported she did not know why Resident #8's care plan had not been updated. An interview with the Director of Nursing on 12/12/24 at 1:52 PM revealed she was familiar with Resident #8 and that she was severely cognitively impaired and had wandering behaviors. She stated in March, she was made aware of an incident by Nurse #4 regarding Resident #8 ingesting an unknown amount of wound cleanser. She reported the day after the incident, it was discussed in the interdisciplinary team meeting, and she verified that MDS Nurse #2 was present. The Director of Nursing reported Resident #8's care plan should have been updated immediately after the interdisciplinary team meeting to reflect the potential for Resident #8 to ingest non-food items. She did not know why Resident #8's care plan had not been updated after she ingested the wound cleanser.

Based on record review, and staff and Adult Protective Services (APS) Intake Social Worker interviews, the facility failed to file a report with the state agency no later than 24 hours after becoming aware of an allegation of misappropriation of resident property and failed to report the incident to APS for 1 of 3 residents reviewed for abuse (Resident #70). The findings included: A review of the facility's abuse, neglect, exploitation and misappropriation policy and procedure revised 11/16/22 read in part: Reporting/Response: Once an allegation of abuse is reported, the Administrator, as the abuse coordinator, is responsible for ensuring that reporting is completed timely and appropriately to appropriate officials in accordance with Federal and State regulations, including notification of Law Enforcement if a reasonable suspicion of crime has occurred. The Abuse Coordinator will refer any or all incidents and reports of resident abuse to the appropriate state agencies. Resident #70 was admitted to the facility 1/05/24. A review of the police department incident report indicated on 5/10/24 at 11:11 AM they received a report that Resident #70 had money stolen from his bank account. A review of the facility's initial allegation report dated 5/30/24 revealed the facility became aware on 5/29/24 that Resident #70's bank statement had several transactions transferring money from his account to a former employee's (Housekeeper #1) mobile payment application account. The report indicated there was reasonable suspicion of a crime, and the alleged misappropriation of resident property was reported to law enforcement on 5/30/24 however it was not reported to Adult Protective Services. The report was completed by the Former Administrator. An interview with the Business Office Manager (BOM) on 12/11/24 at 11:37 AM indicated she did not recall the date but at the end of April she met with Resident #70 to discuss payment of his monthly bill, and he told her he lost his debit card and needed assistance contacting the bank. She revealed they called the bank a few days later and were informed that Resident #70's account had been overdrawn since January and there were several transactions sending money to a mobile payment application account. She stated she reviewed Resident #70's bank statements on 5/10/24 and there were several transactions sending money to various mobile payment application accounts, one of which was Housekeeper #1's. She indicated she contacted the mobile payment application company, and they informed her Housekeeper #1 had opened an account linked to Resident #70's debit card. The BOM revealed she immediately notified the Former Administrator of the concern, and a police report was filed on 5/10/24. A phone interview was conducted with the APS Intake Social Worker on 12/16/24 at 9:27 AM. She stated they had no record of the facility reporting an incident of misappropriation of property for Resident #70. A phone interview with the Former Administrator on 12/12/24 at 8:59 AM revealed the BOM was reviewing Resident #70's bank statements and there were several transactions transferring money from his account to Housekeeper #1's mobile payment application account. He stated the BOM notified him of the concern on 5/10/24 and he filed a police report. He further stated he did not submit an initial allegation report within 2 hours because he wanted to investigate it further along with the police to see if it was anything. He revealed Housekeeper #1 was no longer employed at the facility when the concern was identified. He stated he submitted the initial allegation report on 5/30/24 once the police investigation was completed and they determined no charges would be filed against Housekeeper #1. The Former Administrator indicated because the police did not file charges against Housekeeper #1, he unsubstantiated the allegation of misappropriation and did not file a report with APS.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 9/08/23. This was for two repeat deficiencies that were cited in the areas of self-determination, activities of daily living care provided for dependent residents that were originally cited during a recertification and complaint survey dated 03/21/23, 09/08/23 and subsequently recited during the onsite revisit and complaint survey dated 10/24/23. The area of food procurement was originally cited during a recertification and complaint survey dated 09/08/23 and subsequently recited during the onsite revisit and complaint survey dated 10/24/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: The tag is cross referenced to: F561- Based on observations, record review, resident and staff interview the facility failed to honor resident requests for two showers per week (Resident #2 and Resident #4) for 2 of 4 residents reviewed for choices. During the recertification and complaint survey dated 9/08/22, the facility failed to honor resident request for two showers per week and the facility also failed to honor a resident's request to get out of bed this affected 4 of 6 residents reviewed for choices. During the recertification and complaint survey dated 3/21/22 the facility failed to honor a resident's bathing preferences for 3 of 7 residents reviewed for choices. F677- Based on observations, record reviews, resident, family and staff interviews, the facility failed to provide hair care to a dependent resident for 1 of 3 residents reviewed for activities of daily living (Resident #1). Resident #1 was observed with matted hair while waiting to go for an outside Physician appointment. Resident #1 stated the matted hair was painful and she felt like the staff did not care. During the recertification and complaint survey dated 9/08/23, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living. During the recertification and complaint survey dated 3/21/22 the facility failed to provide facial grooming for 1 of 4 dependent residents reviewed for activities of daily living. F812- Based on observations and staff interviews, the facility failed to date opened items stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents. During the recertification and complaint survey dated 9/08/22 the facility failed to label and date leftover food items available for resident consumption stored in 1 of 1 reach in refrigerator and failed to date pre-filled bowls of cereal stored in the dry storage area located in the main kitchen. These practices had the potential to affect food served to residents. An interview with the Director of Nursing (DON) and Administrator on 10/24/23 at 4:00 PM revealed monthly Quality Assurance (QA) meetings were held to review measures put in place and discussed with the Medical Director and other departments for their response and feedback to issues identified. When issues were identified a review and corrective action plan was implemented and if there was no improvement, the QA committee revisited it. The DON and Administrator felt interventions put into place were beginning to aid in preventing repeat deficiencies but need to be revisited by the QA committee to ensure ongoing compliance in all areas.

Based on observations, record reviews, resident, family and staff interviews, the facility failed to provide hair care to a dependent resident for 1 of 3 residents reviewed for activities of daily living (Resident #1). Resident #1 was observed with matted hair while waiting to go for an outside Physician appointment. Resident #1 stated the matted hair was painful and she felt like the staff did not care. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cancer. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance of two staff members for personal hygiene and was dependent for bathing. It further indicated no rejection of care or behaviors. Review of the nurse's progress notes from 09/08/23 through 10/24/23 revealed no notes regarding Resident #1 refusing showers or personal hygiene care. Review of the Nurse Aide (NA's) documentation of the same period revealed no indication Resident #1 refused hair care. An observation and interview with Resident #1 on 10/24/23 at 10:40 AM revealed Resident #1 sitting in her wheelchair at the nurse's station. Resident #1 stated she was ready and waiting to go to her cancer treatment appointment. The back of Resident #1's hair was matted and protruding over the back of the resident's wheelchair. She was observed to have long, thick hair. Resident #1 stated the last time her hair had been washed was 3-4 weeks prior. She stated she knew her hair was matted because she could not brush it herself due to not being able to lift her arms above her head. Resident #1 stated her matted hair caused her scalp and head to hurt all the time on a pain level of 4 on a 0-10 scale. She stated staff had tried to brush it today, but it hurt too bad. The interview revealed she had told staff her hair was matted, and they were aware of it. She stated her husband had even offered to pay to have her hair cut but the facility did not have a hairdresser. Resident #1 stated, I feel like the staff don't care. Resident #1 then went on to say that it really wasn't the staff's fault because she had thick hair that needed to be cut and the facility did not have a hairdresser. An interview conducted with Resident #1's Family Member #1 on 10/24/23 at 10:48 AM revealed he had wanted Resident #1's hair cut for several months. He stated he had talked with the former Administrator of the facility. The interview revealed the former Administrator had told him they did not have anyone to cut her hair but if he wanted to, they would make an area in the beauty shop for him to wash and cut her hair. The family member stated he had medical conditions himself and he was not able to wash Resident #1's hair or cut it. A review of the undated shower schedule revealed Resident #1 was to receive bathing and personal hygiene twice weekly on Monday and Thursdays during day shift (7AM- 3PM). An interview with Nurse Aide (NA) #1 on 10/24/23 at 10:22 AM revealed he had been assigned to Resident #1 on 10/23/23 on day shift (7A-3P) and had not provided hair care. He stated the hall Resident #1 is on had 12 dependent residents requiring a mechanical lift for transfers including Resident #1. He stated he often had to give the residents bed baths because he could not get them up for a shower due to staffing and bed baths did not always include washing the resident's hair. NA #1 stated Resident #1's hair was matted because nobody was brushing it and with the number of residents on the hall the staff didn't have time. He stated Resident #1 had told him for several months she wanted her hair cut, so he stated he told the nurses, but nothing had been done. The interview revealed Resident #1's hair was matted to the point the staff could not brush it out. An interview with Nurse Aide (NA) #2 on 10/24/23 at 11:05 AM revealed she had been assigned to Resident #1 on the week prior to 10/24/23. She stated she had to get Resident #1 ready for a cancer treatment appointment and had noticed her hair was matted. NA #2 stated Resident #1 was screaming and stated it hurt when she tried to brush the hair because it was matted. She stated, her hair is matted because staff aren't brushing it. The interview revealed she had seen Resident #1's hair matted for the last several months. NA #2 stated she had not told the Nurse on duty about the resident's hair condition. An interview with Nurse #1 on 10/24/23 at 11:38 AM revealed she had been assigned to Resident #1 in the past. She stated she knew Resident #1's hair was matted in the back, but it was to the point the Nurse Aides could not brush it out without hurting the resident. Nurse #1 stated Resident #1 was getting up daily to go out for cancer treatments and staff were brushing the hair over the matted hair to make it less obvious. Nurse #1 stated she had not told the Director of Nursing about Resident #1's hair because she thought everyone knew. An interview with Nurse #2 on 10/24/23 at 12:09 AM revealed she had been assigned to Resident #1 on 10/24/23. Nurse #2 stated Resident #1 had matted hair for several months. She stated she got Resident #1 up on the morning of 10/24/23 for her appointment and tried to brush her hair but it was hurting the resident so she just put what she could in a ponytail. Nurse #2 stated, I did the best I could. The interview revealed Resident #1 had asked Nurse #2 to cut her hair the week prior. She stated she told the Director of Nursing on 10/24/23 after she got her up for the appointment that the resident had matted hair. Nurse #2 stated she did not cut the resident's hair because she did not feel comfortable doing so. An interview with the Director of Nursing on 10/24/23 at 1:24 PM revealed she expected all residents to receive hair care on bath days and when needed by nurse aides. She stated Nurse #2 told her about the matted hair on 10/24/23. The DON stated no staff members had come to her and told her about the matted hair prior to 10/24/23. An interview with the Administrator on 10/24/23 at 2:01 PM revealed that he had only been in the facility 3 weeks. He stated each resident should receive hair care on their shower day and no resident's hair should be in a matted condition. The interview revealed the facility would have someone come in to cut Resident #1's hair and staff would wash the resident's hair.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living (Resident #36). The findings included: Resident #36 was admitted to the facility on [DATE] with diagnoses that included chronic pain. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact and required extensive assistance for personal hygiene and was dependent for bathing. It further indicated no rejection of care or behaviors. Review of the nurse's progress notes from 8/21/23 through 9/8/23 revealed no notes regarding Resident #36 refusing showers or personal hygiene care. Review of the Nurse Aide (NA's) documentation of the same period revealed no indication Resident #36 refused nail care. An observation and interview with Resident #36 on 9/5/23 at 11:41 AM revealed Resident #36 lying in bed with fingernails on both hands that extended out past the end of her fingertips approximately one-half inch in length with chipped burgundy nail polish. Some nails were jagged on the end. Resident #36 indicated she had not received nail care in a month. An observation and interview with Resident #36 on 9/7/23 at 2:44 PM revealed Resident #36 lying in bed and her fingernails remained long with chipped burgundy nail polish. Some nails were jagged on the end. Resident #36 indicated she did not receive nail care in a month, and she did not like her nails to be this long and preferred to have her nails trimmed and manicured. A review of the undated shower schedule revealed Resident #36 was to receive bathing and personal hygiene twice weekly on Monday and Thursdays during day shift (7AM- 3PM). An interview with NA #11 on 9/7/23 at 2:44 PM revealed she had been assigned to Resident #36 on 9/7/23 on day shift (7A-3P) and had not provided nail care due to not knowing Resident #36's assigned bath days and did not have enough assistance to get nail care completed in the last several weeks. NA #11 acknowledged Resident #36's nails were long and jagged and nail polish was chipped. An interview with NA #12 on 9/7/23 at 2:44 PM revealed she had been assigned to Resident #36 on 9/7/23 on evening shift (3PM -11 PM) and had not provided nail care due to not knowing Resident #36's assigned bath days, she did not work the day shift, and did not have enough assistance to get nail care completed in the last couple of weeks. NA #11 acknowledged Resident #36's nails were long and jagged and nail polish was chipped. An interview with the Director of Nursing on 9/8/23 at 4:30 PM revealed she expected all residents to receive nail care on bath days by nurse aides and activity department during manicure activities as allowed.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put in place following a recertification and complaint survey dated 3/21/22. This was for six repeat deficiencies that were cited in the areas of self-determination, accuracy of assessment, care plan timing and revision, activities of daily living care provided for dependent residents, sufficient nursing staffing, and label and storage of drugs and biologicals that were originally cited during a recertification and complaint survey dated 3/21/22 and subsequently recited during the recertification and complaint survey dated 9/8/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: The tag is cross referenced to: F561- Based on observations, record reviews, resident and staff interviews, the facility failed to honor a resident's request to receive two showers per week and the facility also failed to honor a resident's request to get out of bed which affected 4 of 6 residents reviewed for choices. During the recertification and complaint survey dated 3/21/22, the facility failed to honor a residents bathing preference for 3 of 7 residents reviewed for choices. F641- Based on observations, record reviews, resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of limb prosthesis, the area of hospice, and the use of antipsychotic medications for 4 of 22 residents MDS's reviewed. During the recertification and complaint survey dated 3/21/22, the facility failed to accurately code the MDS for diagnoses and for antipsychotic medication review for 1 of 5 residents reviewed for unnecessary medications. F657-Based on record review, resident and staff interviews the facility failed to invite 2 of 2 residents to a care plan meeting that were reviewed for care plans. During the recertification and complaint survey dated 3/21/22, the facility failed to invite 3 of 3 residents to a care plan meeting, failed to update a care plan that addressed a residents suicidal ideations, and attempt for 1 of 5 residents reviewed for unnecessary medications and failed to update a residents' care plan to address interventions related to pressure ulcer prevention for 1 of 5 residents reviewed for pressure ulcers. F677- Based on observations, record reviews, resident and staff interviews, the facility failed to provide nail care to a dependent resident for 1 of 2 residents reviewed for providing activities of daily living. During the recertification and complaint survey dated 3/21/22, the facility failed to provide facial grooming for 1 of 4 residents reviewed for activities of daily living. F725- Based on observations, record reviews and staff interviews, the facility failed to provide sufficient nursing staff resulting in residents not having their choices honored for receiving two showers per week, failed to honor a residents request to get out of bed and the facility failed to provide nail care for 5 of 5 residents reviewed for choices and activities of daily living. During the recertification and complaint survey dated 3/21/22, the facility failed to maintain sufficient nursing staff to provide scheduled showers and facial grooming. These failures affected 3 of 7 residents in the area of activities of daily living. F761- Based on observations, record reviews and staff interviews, the facility failed to discard expired medications and failed to store a controlled substance in a permanently affixed compartment in the refrigerator in 1 of 1 medication room (main medication room) for review of medication storage. During the recertification and complaint survey dated 3/21/22, the facility failed to remove medications from room (A-101), failed to remove mediations from 1 of 6 hallway side railed (F-hall), failed to remove an undated and unlabeled insulin pen, failed to remove expired and undated breathing solutions, failed to remove an unopened insulin pen from 3 of 5 medication carts (B Hall, C hall, and F hall) reviewed for medication storage. An interview with the Director of Nursing (DON) and Administrator on 9/8/23 at 4:00 PM revealed monthly Quality Assurance (QA) meetings were held to review measures put in place and discussed with the Medical Director and other departments for their response and feedback to issues identified. When issues were identified a review and corrective action plan was implemented and if there was no improvement, the QA committee revisited it. The DON and Administrator felt interventions put into place were beginning to aid in preventing repeat deficiencies but need to be revisited by the QA committee to ensure ongoing compliance in all areas.

Based on observation, record review, resident, staff, and Nurse Practitioner interview the facility failed to safely transfer a resident from a wheelchair to bed when one staff member performed a stand pivot transfer when the resident required a two-person assistance with stand pivot transfers (Resident #55) for 1 of 3 residents reviewed. Resident #55 was assisted with a stand pivot transfer by a Nurse Aide and heard and felt a pop in her right leg and sustained a closed fracture of the patella (small bone in front of knee joint). The findings included: Resident #55 was readmitted to the facility on [DATE]. Her current diagnoses included fracture of patella (small in front of knee join). Review of a Transfer mobility status dated [DATE] indicated that Resident #55 required a sit to stand lift. Review of an Activities of Daily Living care plan revised on [DATE] included the following intervention: the resident required two-person assistance to pivot between transfers. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #55 was cognitively intact and required one person assistance with transfers. Review of a document titled Report of Resident Other Event dated [DATE] read in part, resident reports that when she was being transferred from wheelchair to bed, she felt her knee move. The severity level of the injury read; minor injury (abrasion, bruise, laceration, pain, skin tear, sprains). The Nurse Practitioner (NP) was notified by the Assistant Director of Nursing (ADON). Review of a nurses note by the ADON dated [DATE] at 12:28 PM read in part, notified by a visitor that Resident #55 was in bed crying. Resident #55 is in bed, crying. Reports that her right knee hurts like I died and went to hell. Resident #55 stated that during a transfer her knee popped or something. Resident #55 tense and crying out in pain as her pants were adjusted to visualize the knee. Denies pain or tenderness when right knee area was touched. Called placed to the NP and new orders obtained for Xray. Review of a Radiology Report dated [DATE] from the facility read in part; Right knee conclusion: acute appearing periprosthetic (fracture that occurred around the joint that has been replaced). Recommend orthopedic consult. An emergency room (ER) evaluation dated [DATE] read in part; patient presented to ER after injuring her right knee. She was being placed in her bed when she heard a pop and had sudden pain in the right knee. Her foot was planted when she twisted. At rest the pain is negligible but with any type of motion it becomes significant. She is unable to bear weight on right lower extremity. She does have a history of foot drop (difficulty lifting the foot) on the right side. The physical examination revealed moderate swelling noted to the right knee, moderate tenderness to gentle palpation. Patient unable to straighten out the knee due to pain. Knee Xray report; large lipohemarthrosis (presence of intra-capsular floating fat in a joint cavity most common cause is traumatic knee injury), possible avulsion (pulling or tearing) injury of part of the patella. Otherwise, no distinct fracture or dislocation. Disposition: will give patient pain medication, knee immobilizer and referral to orthopedics. Review of a Physician Progress Note dated [DATE] read in part; Chief complaint: nondisplaced fracture of the bone in the lower leg. History of present illness: the patient was being transferred and unfortunately suffered the above fracture. She was sent to the ER, no surgery required but she does have a brace and will follow up with orthopedic surgeon. She stated that by and larger her pain is controlled except with she must be transferred. An orthopedic consult dated [DATE] read in part, Resident #55 had a recent injury while being moved and felt a painful pop in her knee. Xray suggest avulsion (pulling or tearing) injury of the patella. Today she presents with pain that is a 12 on a scale from 0 to 10. The assessment and plan read in part, superior patella (small bone in front of knee joint) fracture right knee. An observation and interview were conducted with Resident #55 on [DATE] at 1:25 PM. Resident #55 was resting in bed with her right leg elevated on pillows. There was a knee immobilizer on her right knee that extended down to her mid-calf. She reported that approximately ,d+[DATE] weeks ago she had just gotten back from a doctor's appointment and wanted to go back to bed. She stated she asked Nurse Aide (NA) #7 to lay her down. Resident #55 stated that she put her knees between NA #7 ' s knees and wrapped my arms around her neck and NA #7 had her arms around my waist and stood me up and pivoted me to the bed, but my legs did not pivot. She stated that she and NA #7 both heard and felt a pop in her right knee and it was so painful on a scale of ,d+[DATE] it was a 12. Resident #55 stated that they ordered some Xray ' s and once those were done, they sent me over to the ER for evaluation and confirmed a fracture in my knee. Resident #55 stated several days later she saw her orthopedic doctor and he again took several Xray ' s and confirmed the fracture and drew some fluid off the knee which helped ease the pain. NA #7 was interviewed on [DATE] at 2:19 PM. NA #7 stated that she was working in activities on [DATE] and had accompanied Resident #55 to her doctor's appointment when they returned to the facility Resident #55 wanted to lay back down. NA #7 stated that she done it like she had seen therapy do it by pivoting Resident #55. She stated that Resident #55 was in a high back wheelchair, and she placed her knees between Resident #55's knees and she wrapped her arms around my neck, and I grabbed the back of her pants and stood her up. As Resident #55 stood up NA #7 stated that they both heard and felt a pop and Resident #55 stated ouch that hurts, NA #7 stated she finished pivoting Resident #55 to the side of the bed and sat her on the edge of the bed and then lifted both of her legs into the bed. Once Resident #55 was in the bed, NA #7 stated she reported the incident to the nurse on the hallway, but she could not recall who that was but also reported the incident to the ADON. NA #7 stated that she did not know if Resident #55 required a mechanical lift or what her transfer status was. She stated she had reviewed her Kardex (care plan) previously and could not find the information. NA #7 did say she did look in the wheelchair to see if there was mechanical lift pad under Resident #55 but there was not, so she assumed that meant Resident #55 did not require a lift for transfers. The ADON was interviewed on [DATE] at 2:45 PM. The ADON stated that on [DATE] someone but she could not recall who reported that Resident #55 was in her room crying. She stated she went down to Resident #55's room to see what was going on. Resident #55 told the ADON that when she had gotten back from her doctor's appointment and the NA was transferring her from her wheelchair to her bed, she felt a pop in her knee. The ADON stated that there were no obvious signs of bruising, swelling or redness, and stated that she could not recall if Resident #55 was in pain or not, nothing stands out in my mind. The ADON stated she contacted the NP and an Xray was ordered and then the DON and Administrator were made aware of the incident. She added that the Xray report came back, and she could not recall exactly what it said but it suggested a possible fracture, so the NP was made aware and gave an order to send Resident #55 to the ER for evaluation and treatment. When Resident #55 returned she stated that she had an appointment with the orthopedic provider and a knee immobilizer in place. The ADON stated that prior to the incident Resident #55 was a lift transfer but did not know if it was a sit to stand lift or a total mechanical lift transfer. After the incident Resident #55 was reassessed and determined to be a total mechanical lift for transfers. The ADON stated that the day after she returned for the ER, she went down to check on Resident #55 and she was in a lot of pain and when asked to rate her pain she replied, on a scale of ,d+[DATE] it is a 12. The DON was interviewed on [DATE] at 3:05 PM. The DON stated that from what she could recall on [DATE] Resident #55 returned from a doctor's appointment and NA #7 transferred her by herself and during the transfer heard and felt a pop in Resident #55's knee. NA #7 notified the ADON, and the NP was contacted and an Xray ordered then Resident #55 was sent to the ER for evaluation and returned shortly thereafter. Prior to the incident the DON stated Resident #55 was a two person assist with transfer, but she was not sure if the transfer required a lift or not but stated she definitely required 2 person assist with transfers. The DON stated that NA #7 was suspended for not following the plan of care for Resident #55 and transferring her alone. After the incident all the resident transfer/statuses were updated, and all the staff were reeducated on the Kardex (care plan) and where to locate the transfer status and the proper way to transfer a resident. The Administrator was interviewed on [DATE] at 4:50 PM. The Administrator stated that when they found out about the fracture, they interviewed NA #7 and learned that she had pivoted Resident #55 from the wheelchair to the bed. When NA #7 was asked why she had done that she replied that she was confident in her ability to perform the transfer that way. The Administrator stated that prior to the incident Resident #55 required a lift for her transfers along with 2-person assistance and that was what NA #7 should have done. Following the incident all the residents had an updated transfer/mobility status assessment completed and their care plan/Kardex update. The staff were reeducated on where to locate the information and the importance of how and why to follow the care plan. The NP was interviewed on [DATE] at 2:00 PM. The NP stated that on [DATE] Resident #55 had been out to an appointment and when she returned asked to go to bed. The staff member transferred her from the wheelchair to the bed and during the transfer they heard and felt a pop in her leg. The NP stated she was not in the facility that day but was contacted by the ADON and gave an order for an Xray that came back suspicious for a fracture. Resident #55 was sent to ER for evaluation and after an orthopedic consult the fracture was confirmed of the right patella. She added she evaluated Resident #55 on [DATE] and she was still in a lot of pain and her pain medications were adjusted to help keep her as comfortable as possible. The NP indicated that Resident #55 had taken oral steroids for years along with her immobility would cause her bones to be brittle and more prone to fractures. The facility provided the following Corrective Action Plan with a completion date of [DATE]: 1. On [DATE] resident was being transferred from wheelchair to bed by Nurse Aide (NA) #7 when NA #7 heard resident ' s right knee pop. NA #7 made sure resident was in bed and immediately informed the nurse. Nurse #5 completed a visual assessment of resident right knee. Assessment revealed no swelling, redness, or bruising to right knee. At that time vital signs obtained by nurse. Nurse #5 then reported the incident to the Assistant Director of Nursing (ADON). The ADON also assessed resident's right knee; ADON ' s assessment revealed no swelling/[CONDITION(S)], no redness, no bruising. Right knee palpated, no facial grimacing or tendering noted. The ADON contacted the Nurse Practitioner (NP) and an order was obtained for an X-ray to the right knee. Nurse #5 reported the X-ray results to the ADON. The X-ray report stated periprosthetic fracture and recommended an orthopedic consult. ADON contact the NP and an order was given to send resident to the emergency room (ER) for evaluation. Emergency Medical Services (EMS) arrived around 4:10 PM, stabilized residents ' right leg and transferred resident to stretcher via 4 persons. Resident out of facility around 4:25 PM. On [DATE] resident evaluated in the local emergency department for right knee pain and x-ray performed. The x-ray report stated: Right Total knee arthroplasty is in normal alignment without evident of hardware failure or loosening. Large lipohemarthrosis present with heterotopic calcification superior to the patella. No possible distinct fracture or dislocation. Bony mineralization is normal. Vascular calcifications present. Resident was discharged back to the facility on third shift with order for knee immobilizer with referral to orthopedics. 2. On [DATE] NA #7 was immediately suspended pending investigation. No other residents were affected. As a result of the investigation, it was determined that NA #7 did not follow the resident Kardex/care plan regarding transfer. Resident required 2 person assist with transfers and NA#7 transferred resident alone. On [DATE] NA #7 was terminated. 3. Starting on [DATE] nursing staff including Nurse Aides will be reeducated by the Director of Nursing/Nursing management regarding transfers and where to find the appropriate information for individual resident transfers. New staff will be educated upon hire during orientation: a. Transfer assessments will be completed for residents residing in the facility by nursing management. b. Resident Kardex will be reviewed and updated with the results of the transfer assessments. c. Resident care plans will be reviewed and updated to correspond with transfers assessment and Kardex by nursing management. d. Therapist and Director of Nursing educated nursing staff on mechanical lift, sit to stand lift, and assist to ambulate using transfer belt. e. The DCS/Nurse Manager/Designee will observe a transfer for nursing employee to ensure that appropriate transfer technique is being demonstrated during resident transfers. f. Starting on [DATE] random weekly observations of transfers will be conducted by Director of Nursing/Nurse Manager/Designee for three (3) employees to ensure that appropriate transfer technique is being sustained by nursing staff during resident transfer. g. An impromptu QA/PI meeting was held on [DATE] to discuss the plan of correction and corrective measures. 4. Results of the random weekly observations will be discussed at the monthly QA/PI meeting for three (3) months to sustain substantial compliance. 5. Allegation of compliance date: [DATE]. The Corrective Action plan was validated on [DATE] and concluded the facility had implemented an acceptable corrective action plan on [DATE]. Interviews with current nursing staff including agency staff revealed the facility had provided education and training on transfer status assessments, where to find the results of the transfer assessment, and how to safely transfer a resident using stand pivot technique and/or mechanical lift. Each nursing staff member conducted competency sheets to verify knowledge of how to operate the mechanical lift. The audits conducted starting on [DATE] revealed the facility management observed transfers to ensure that proper transfer technique was being utilized by staff. The audits continued weekly through the validation date. The corrective action plan was reviewed with the Quality Assurance committee on [DATE].

Based on record review and staff interview the facility failed to implement their abuse policy in the area of reporting; 2 staff members (Nurse Aide #2 and Nurse Aide #3) failed to immediately report an allegation of abuse when they witnessed Nurse #1 and Nurse Aide #1 in a struggle with a resident over a cigarette and cigarette lighter for 1 of 1 residents (Resident #1). Findings included: Review of the facility abuse, neglect, and misappropriation of resident property policy dated 11/30/2014 revealed a section titled: Reporting/Response, this section states any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made to the Administrator. Resident #1 was readmitted to facility on 2/26/2022 and was discharged to another facility on 4/26/2022. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent Minimum Data Set (MDS), a quarterly assessment, dated 2/6/2022, revealed Resident #1 was cognitively intact and was required supervision to limited assist from one staff for Activities of Daily Living (ADL). Review of Nursing Progress note dated 3/14/2022 at 6:41 PM by Nurse #1 revealed patient was witnessed by staff outside smoking 3/13/2022 around 9 PM. Attempted to provide patient with safety/smoking education with no success. Patient became verbally and physically abusive toward this nurse as well as the NA present. Cigarette and lighter were retrieved from the patient. Resident #1 then stated he would get more from someone, and he would just start smoking in his room. 15-minute checks initiated. Patient made no attempts this shift to smoke in his room. An interview was conducted with NA #2 on 5/17/2022 at 10:45 AM and a 2nd interview by telephone on 5/18/2022 at 8:41 AM. She stated she and NA #3, got Resident #1 up out of bed on 3/13/2022 around 9:30 PM. She stated they told Resident #1 that we didn't know if they would let him go outside that time of night. She stated she was at the nursing station not long after he had gone outside, and they (Nurse #1 and NA #1) were bringing him back inside. They were holding him back; they were holding his arms so that he couldn't punch. They were trying to get his lighter and cigarettes. This occurred at the nurse's station. She stated she observed his gown coming up starting to go up towards his head, where they were trying to get his cigarettes, and his brief was coming down, it was loose, and she walked away. She stated she did not want to be a witness to all of that. She stated the reason she did not report the incident on 3/13/2022 was because she thought Nurse #1 would report it, since she was involved and was in charge. She stated she did not work again from the end of her shift on 3/13/2022 until she reported for second shift on 3/16/2022. She then realized that the incident had not been reported, so she went to the Director of Nursing on 3/16/2022 around 4:00 PM and reported to her that Resident #1 was stating he had been hit by staff. An interview was conducted by telephone with NA #3 on 5/17/2022 at 11:00 AM and a 2nd telephone interview on 5/18/2022 at 9:18 AM. She stated she had let Resident #1 go outside on 3/13/2022. She stated she did not know he wanted to go outside to smoke. She stated that while he was outside, NA #1 had been outside and saw him smoking. NA #3 stated NA #1 came back inside and got Nurse #1 and they brought Resident #1 back inside. She stated she and NA #2 had been at the Nurse's station when Resident #1 was brought to the station by NA #1 and Nurse #1, and they were trying to get the cigarettes and lighter from him. She stated NA #2 stated to her, this is wrong, and I won't be involved in it, they should have called the Administrator or the Law. She stated she observed NA #1 standing behind Resident #1's wheelchair, she was holding his arms and Nurse #1 was trying to get the cigarettes and lighter out of his pocket. She stated she observed Resident #1's butt-crack showing, and his gown was coming off and his brief was coming down. She stated she and NA #2 left the nurse's station together. NA #3 stated the reason she had not reported the incident on 3/13/2022 was because she had already given a written statement for the Administrator and Director of Nursing, and no one did anything for 3 days. She stated she did not know who else to report the incident too, since Nurse #1 was there, Nurse #1 should have reported it, and she didn't know why Nurse #1 had not reported the incident to the Director of Nursing. She stated she felt uncomfortable during the incident about how Resident #1 was being treated. An interview was conducted with Nurse #1 on 5/17/2022 at 12:10 PM and again on 5/18/2022 at 4:48 PM. Nurse #1 stated she called the Director of Nursing on the evening of 3/13/2022, around 10 PM, after the incident with Resident #1. She stated she told the Director of Nursing that Resident #1 had been caught outside of the building smoking by NA #1, and she and NA #1 had brought him back inside the building. She stated she told the Director of Nursing she had asked Resident #1 to give her his cigarettes and lighter and he had refused. She stated she told the DON that she had physically retrieved the cigarettes and lighter from him. She stated the DON did not ask her how she had retrieved the cigarettes and lighter. Nurse #1 stated the reason she did not inform the Director of Nursing on 3/13/2022, while she had her on the telephone, that there had been a struggle getting the cigarettes and lighter from Resident #1 was because she did not feel there had been a struggle at the time, she stated she felt like it was a safety issue to retrieve the cigarettes and lighter from him. Nurse #1 stated that Resident #1 was the one swinging at her and trying to hit her when she tried to get the cigarettes and lighter. She stated she never hit Resident #1. A telephone interview was conducted with NA #1 on 5/17/2022 at 12:30 PM. NA #1 stated the reason why she did not report the incident with Resident #1 to anyone was because Nurse #1 had called the Director of Nursing after the incident to tell her what happened. She stated Nurse #1 had notified the Director of Nursing that Resident #1 had been caught outside smoking and she and Nurse #1 had to bring him back inside the facility. She stated she did not feel that she needed to do anything else or report to anyone else about the incident. She stated she was only trying to keep Resident #1 from sliding out of his wheelchair onto the floor and keep him from hitting Nurse #1, since he was swinging his arms at Nurse #1. An interview was conducted with DON on 5/17/2022 at 2:15 PM. DON stated she was notified, by telephone, on 3/13/2022 around 10:00 PM, by Nurse #1. She stated she was told by Nurse #1 that Resident #1 had been outside smoking and that she and NA #1 had brought Resident #1 back inside the building and got his cigarettes and lighter from him. DON stated she did not know how they got the cigarette and lighter from Resident #1 nor was she aware that a scuffle had occurred between Resident #1, Nurse #1, and NA #1 until Wednesday, 3/16/2022, when NA #2 had reported to her. DON stated she did not know how the cigarette and lighter were retrieved from Resident #1, she did not ask, she assumed he had given them to Nurse #1 when asked. DON stated Resident #1 was documented as being a smoker on admission. She stated she was not aware he had been requesting to go to another facility so he could smoke. DON stated as soon as she was made aware an allegation of abuse had been made by Resident #1, she immediately notified the Administrator, had the ADON assess Resident #1 for injuries, and the investigation was started. An interview was conducted with Administrator on 5/18/2022 at 11:00 AM. She stated she and the DON were responsible for abuse investigations. She stated she was not in the facility with the alleged allegation of abuse was noted on 3/13/2022. She stated she first heard there was an allegation of abuse on 3/16/2022, late in the afternoon, when she was contacted by telephone by the DON. She stated she was informed Resident #1 was stating he had been hit by staff. She stated ADON went immediately and conducted an interview with Resident #1 and assessed him for injuries. Administrator stated she and DON interviewed NA #2 by telephone together and the alleged employees involved, Nurse #1 and NA #1 were suspended pending outcome of the investigation. She stated Resident #1 was furious when he was brought back inside the building on 3/13/2022, after he had been found smoking, but the staff did not put their hands on him. She stated she did not ask Nurse #1 what she had reported to DON on 3/13/2022. The facility provided the following corrective action plan with at completion date of 3/31/2022. 1. On 3/16/2022 at approximately 4:00 PM Resident #1 was immediately assessed by the Assistant Director of Nursing (ADON) for any injuries related to the allegation of being punched in the chest. No redness or bruising of any kind was found on the resident. At that time the resident was interviewed by the ADON, stating a nurse (Nurse #1) had punched him in the chest when he was caught smoking on 3/13/2022. On 3/16/2022 at approximately 4:00, Nurse #1 and Nurse Aide #1 were interviewed and provided written statements. Nurse Aide #2 and Nurse Aide #3 were verbally interviewed by the Director of Nursing on 3/16/2022 with no changes noted from statement they gave on 3/13/2022. On 3/16/2022 at approximately 5:00 PM staff members (Nurse #1 and Nurse Aide #1) accused of hitting the resident were suspended pending the investigation. On 3/17/2022 at approximately 3:00 PM the police were notified. An initial report was turned in to the state on 3/16/2022 4:18pm and the investigation was completed and submitted to DHSR on 3/22/2022 at 4:36 PM. APS was contacted by the administrator on 3/17/2022 at approximately 10:00 AM. The Medical Director interviewed the resident regarding general conditions of his health on 3/22/2022 in order to obtain resident's state of mind to include how things have been going and has anything new happened. The resident stated no and made a request for brand name [MEDICATION(S)]. At no time did he report abuse of any kind to the physician. 2. On 3/17/2022 current residents with a BIMS of 8 or greater were interviewed by Social Services Director regarding abuse and if any staff member had hit them, no new concerns were voiced. Additionally, on 3/16/2022 and 3/17/2022 current resident with a BIMs of 7 and below were given a full body skin assessment by the Director of Nursing and the Assistant Director of Nursing to determine if there were any injuries of unknown origin or injuries that could be related to abuse, no new areas of concern. 3. On 3/17/2022 current staff, to include Nurses and Nurse Aides, housekeeping/laundry, dietary, therapy and all department heads were re-educated on the abuse policy to include any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately to the Administrator and to other officials in accordance with State law. The facility is expected to report to DHSR no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. In the absence of the Administrator, the Director of Nursing is the designated abuse coordinator. Education also included if a resident is combative make sure that the resident is safe and walk away. Do not initiate physical contact if the resident's behavior is escalating. Touching can trigger violence in some. Provide time for the resident to calm down and re-approach. Employees are trained to protect residents from abuse at all times, including intervening with said abuse if they witness it. Notify police if additional assistance is needed. All new staff will be educated upon hire during orientation. All staff were educated on 3/17/2022 or prior to their next shift. The education was provided by the Director of Nursing. 4. Residents will be asked at least three times weekly for 12 weeks during daily rounds of the department heads; has any staff member mistreated/abuse/neglect you since you have been a resident here? Has any staff member taken or misused your property since you have been a resident here? Are you fearful of any staff member while residing here? Do you know who to report abuse to? Are you fearful of retaliation for reporting abuse/neglect? The department head will report findings to the Administrator and/or designee in stand down meeting, daily times five per week. 5. The Administrator is responsible for implementing this plan. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, Certified Nurse Aide, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and MDS Nurse. Results of audits will be reported to Quality Assurance Performance Improvement Committee monthly for three months. Allegation of Compliance 3/31/2022 The Corrective Action plan was validated on 5/26/2022 and concluded the facility had implemented an acceptable corrective action plan on 4/21/2022. Interviews with current nursing staff including agency staff revealed the facility had provided education and training on abuse, notify supervisor immediately, ensure resident is safe and the Administrator is Abuse Coordinator. The audits conducted starting on 3/30/2022 revealed residents were asked about abuse and if they had been abused. Skin checks were completed for all non-alert and oriented Residents by 3/17/2022.The audits continued weekly through the validation date. On 5/26/2022 there was sufficient evidence to support the Facility's Corrective Action Plan was implemented and carried out by 3/31/2022.

Based on record review, resident, hospice nurse and staff interviews, the facility failed to protect a resident's right to be free from mistreatment for 1 of 1 resident investigated for staff to resident abuse (Resident #1) when 2 staff members caught Resident #1 outside smoking and brought him back into the facility and held his arms to remove a cigarette and cigarette lighter from his possession. During the altercation with staff, Resident #1's gown and brief became displaced exposing Resident #1's body at the centrally located nursing station making him feel ashamed. Findings included: Resident #1 was readmitted to facility on 2/26/2022 and was discharged to another facility on 4/26/2022. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent Minimum Data Set (MDS), a quarterly assessment, dated 2/6/2022, revealed Resident #1 was cognitively intact and required supervision to limited assist from one staff for Activities of Daily Living (ADL). Review of the Facility Incident Report dated 3/13/2022, revealed resident #1 found smoking outside and telephone report to Director Nursing on 3/13/2022 at 10:15 PM, report was marked as did not feel incident was abuse. Review of Nursing Progress note dated 3/14/2022 at 6:41 PM by Nurse #1 revealed, Patient was witnessed by staff outside smoking 3/13/2022 around 9:00 PM. Attempted to provide patient with safety/smoking education with no success. Patient became verbally and physically abusive toward this nurse as well as the NA present. Cigarette and lighter were retrieved from the patient. Resident #1 then stated he would get more from someone, and he would just start smoking in his room. 15-minute checks initiated. Patient made no attempts this shift to smoke in his room. Telephone interview with Resident #1 was conducted on 05/17/22 at 10:40 AM. Resident #1 stated that on 03/13/22 around 8:30 PM he asked one of the NAs to take him outside for some fresh air. Resident #1 stated that he knew the facility was a nonsmoking facility and he believed the staff did know he was going to smoke. After the NA pushed Resident #1 to the gazebo she returned to the facility and Resident #1 stated he began to smoke a cigarette. Resident #1 explained NA #1 was outside smoking saw him smoking and instructed him to put the cigarette out and he replied no, I have been asking for 4 months to go to a smoking facility. NA #1 returned to the facility and then came back outside with Nurse #1, they pushed him back into the facility in his wheelchair to the nurse's station. They (Nurse #1 and NA #1) told me to give me my cigarette and lighter and I replied, no, I am not a child. Then NA #1 held my arms behind my back as Nurse #1 ripped the pocket off my gown trying to get the cigarette lighter. Then Nurse #1 hit him with an open hand in the chest. Resident #1 stated he was embarrassed and ashamed that the other staff saw the incident and his exposed body. Resident #1 stated he was screaming at them to leave him alone and the staff continued to try and get cigarette and lighter. Resident #1 added he was scared. A telephone interview was conducted on 5/17/2022 at 12:10 PM with Nurse #1. She stated she and NA #1 had gone outside to retrieve Resident #1 and bring him back inside, because he was outside smoking. She stated when they were at the nurse's station, she asked Resident #1 to give them the cigarettes and lighter. Nurse #1 stated that Resident #1 began to swing at her and hit her several times. She stated NA #1 tried to block those strikes with her arms. Nurse #1 revealed she grabbed the cigarette lighter from a pocket on Resident #1's gown. She stated Resident #1's gown was always in place, and he was never exposed. Nurse #1 stated at no time was Resident #1's arms held behind his back. She stated she did not hit Resident #1 and did not rip the pocket off his hospital gown. She stated no one had instructed her to take the items off Resident #1. Nurse #1 stated she took the items from him because he would not voluntarily give them to her. She stated it was a safety issue, he was on oxygen, but he was not on oxygen during the incident. Nurse #1 stated she had immediately notified the Director of Nursing (DON), by telephone about the incident. She stated she had informed the Director of Nursing that she had physically took the cigarettes and lighter from him. A telephone interview was conducted with NA #1 on 5/17/2022 at 1:30 PM. She stated on 3/13/2022, on second shift, she had observed Resident #1 outside smoking, he became aggressive when she asked him to put his cigarette out. She revealed she told Nurse #1 and they brought him back inside. She stated he was moving around in his wheelchair, and was starting to get sideways in the wheelchair, when she and Nurse #1 were trying to get the cigarettes and lighter from him. She indicated she was on the side of the wheelchair, and she put her arm underneath his arm, like when you transfer a resident, just for a couple of seconds to keep him from falling out of the wheelchair. She stated Resident #1 was never exposed and no one hit him. An interview was conducted with NA #2 on 5/17/2022 at 10:15 AM. She stated she and NA #3, got Resident #1 up out of bed on 3/13/2022 around 9:30 PM. She stated they told Resident #1 that they didn't know if they would let him go outside that time of night. She stated she was at the nursing station not long after he had gone outside, and they (Nurse #1 and NA #1) were bringing him back inside. They were holding him back; they were holding his arms so that he couldn't punch. They were trying to get his lighter and cigarettes. This occurred at the nurse's station. She stated she observed his gown coming up starting to go up towards his head, where they were trying to get his cigarettes, and his brief was coming down, it was loose, and she walked away. She stated she did not want to be a witness to all of that. She stated she had been told that she should not put her hands on anyone unless they are going to get hurt or she was providing care. She stated she was not real sure what was going to happen, the nurse was standing right there. She stated the only thing she observed was Nurse #1 and NA #1 touching was his arms. Resident #1 was saying xxxx xxxx, quit it, let me go, in a very loud voice. He threw the lighter on the floor, they were digging for the lighter. An interview was conducted by telephone with NA #3 on 5/17/2022 at 11:00 AM. She stated she had let Resident #1 go outside on 3/13/2022. She stated she did not know he wanted to go outside to smoke. She stated that while he was outside, NA #1 had been outside and saw him smoking. NA #3 stated NA #1 came back inside and got Nurse #1 and they brought Resident #1 back inside. She stated she and NA #2 had been at the Nurse's station when Resident #1 was brought to the station by NA #1 and Nurse #1, and they were trying to get the cigarettes and lighter from him. She stated NA #2 stated to her, this is wrong, and I won't be involved in it, they should have called the Administrator or the Law. She stated she observed NA #1 standing behind Resident #1's wheelchair, she was holding his arms and Nurse #1 was trying to get the cigarettes and lighter out of his pocket. She stated she observed Resident #1's butt-crack showing, and his gown was coming off and his brief was coming down. She stated she did not see anyone hit Resident #1. She stated she and NA #2 left the nurse's station together. She stated that Resident #1 was shaking all over after the incident and his blood pressure was up. An interview was conducted with NA #4 on 5/17/2022 at 11:30 AM. She stated she had been standing at the nurse's station on 3/13/2022 around 9:00 PM when Nurse #1 and NA #1 brought Resident #1 back inside from smoking. She stated he was brought to the nurse's station and Nurse #1 noticed he had cigarettes in the pocket of his hospital gown, he was moving around and swinging his hands to prevent them from getting his cigarettes. She stated Nurse #1 was verbally arguing with Resident #1 and struggling with him, and he was sliding in his wheelchair, NA #1 was holding him up with her arm around his chest, so he would not slide onto the floor. She stated Resident #1's arms were not behind his back, and she did not see anyone hit him. NA #4 stated normally staff would not take a resident's property from them physically, but he said he was going to smoke in his room. NA #4 stated she felt like Resident #1 was safe during the incident. An interview was conducted with DON on 5/17/2022 at 2:15 PM. DON stated she was notified, by telephone, on 3/13/2022 around 10:00PM, by Nurse #1 that Resident #1 had been outside smoking. She stated she was told by Nurse #1 that she and NA #1 had brought Resident #1 back inside the building and got his cigarettes and lighter from him. DON stated she did not know how they got the cigarette and lighter from Resident #1 nor was she aware that a scuffle had occurred between Resident #1, Nurse #1, and NA #1 until Wednesday, 3/16/2022, when NA #2 had reported to her. DON indicated she called the Administrator immediately and had the ADON perform a skin assessment on Resident #1. DON stated she did not know how the cigarette and lighter were retrieved from Resident #1, she did not ask, she assumed he had given them to Nurse #1 when asked. DON stated Resident #1 was documented as being a smoker on admission. She stated she was not aware he had been requesting to go to another facility so he could smoke. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/17/2022 at 1:45 PM. She stated on her arrival to work on the morning of 3/14/2022, she had been met at the door by Nurse #1, who was leaving for the day. She was handed an incident report and a baggie with a partially smoked cigarette and a lighter. She stated Nurse #1 told her that Resident #1 had been outside smoking last night (3/13/2022). She stated Nurse #1 told her that Resident #1 had become verbally abusive to them when they asked him for the cigarettes and lighter. ADON stated she did not recall Nurse #1 telling her there had been a struggle to get the cigarettes and lighter from Resident #1. ADON stated she became aware there had been a struggle with Resident #1 on Wednesday, 3/16/2022, when she was asked by the Director of Nursing (DON) if she was aware of a struggle occurring between Resident #1 and staff. ADON stated she was asked to assess Resident #1 for injuries and conduct an interview with him. She stated she did not find any concerns, except for soreness in his arms. ADON stated she would have preferred staff remove the cigarette and lighter if they could see them, for example laying on his lap or beside him in the wheelchair, but she was not 100% sure about them searching him. ADON stated when she had interviewed staff, she was told they held his arms down beside of him. She stated Resident #1 had started to swing at Nurse #1 and NA #1 had put her arms up around Resident #1 to block him from hitting Nurse #1 and to keep him from sliding out of the wheelchair. ADON demonstrated how she was shown NA #1 had put her arms around Resident #1, she positioned herself behind the resident with one arm around his upper chest and held one arm with one hand, and with the other hand, she demonstrated holding the other arm, to keep him from sliding out of the chair. An interview was conducted with Administrator on 5/18/2022 at 11:00 AM. She stated she and the DON were responsible for abuse investigations. She stated she was not in the facility with the alleged allegation of abuse was noted on 3/13/2022. She stated she first heard there was an allegation of abuse on 3/16/2022, late in the afternoon, when she was contacted by telephone by the DON. She stated she was informed Resident #1 was stating he had been hit by staff. She stated ADON went immediately and conducted an interview with Resident #1 and assessed him for injuries. Administrator stated she and DON interviewed NA #2 by telephone together and the alleged employees involved, Nurse #1 and NA #1 were suspended pending outcome of the investigation. She stated Resident #1 was furious when he was brought back inside the building on 3/13/2022, after he had been found smoking, but the staff did not put their hands on him. She stated she had specifically asked staff if Resident #1 had been abused and was told no. She stated Resident #1 had wanted to go to another facility so he could smoke, and the facility worked very hard on that for him. She stated she did not ask Nurse #1 what she had reported to DON on 3/13/2022. The facility provided the following corrective action plan with at completion date of 3/31/2022. 1. On 3/16/2022 at approximately 4:00PM Resident #1 was immediately assessed by the Assistant Director of Nursing (ADON) for any injuries related to the allegation of being punched in the chest. No redness or bruising of any kind was found on the resident. At that time the resident was interviewed by the ADON, stating a nurse (Nurse #1) had punched him in the chest when he was caught smoking on 3/13/2022. On 3/16/2022 at approximately 4:00, Nurse #1 and Nurse Aide #1 were interviewed and provided written statements. Nurse Aide #2 and Nurse Aide #3 were verbally interviewed by the Director of Nursing on 3/16/2022 with no changes noted from statement they gave on 3/13/2022. On 3/16/2022 at approximately 5:00pm staff members (Nurse #1 and Nurse Aide #1) accused of hitting the resident were suspended pending the investigation. On 3/17/2022 at approximately 3:00pm the police were notified. An initial report was turned in to the state on 3/16/2022 4:18pm and the investigation was completed and submitted to DHSR on 3/22/2022 at 4:36pm. APS was contacted by the administrator on 3/17/2022 at approximately 10:00am. The Medical Director interviewed the resident regarding general conditions of his health on 3/22/2022 in order to obtain resident's state of mind to include how things have been going and has anything new happened. The resident stated no and made a request for brand name [MEDICATION(S)]. At no time did he report abuse of any kind to the physician. 2. On 3/17/2022 current residents with a BIMS of 8 or greater were interviewed by Social Services Director regarding abuse and if any staff member had hit them, no new concerns were voiced. Additionally, on 3/16/2022 and 3/17/2022 current resident with a BIMs of 7 and below were given a full body skin assessment by the Director of Nursing and the Assistant Director of Nursing to determine if there were any injuries of unknown origin or injuries that could be related to abuse, no new areas of concern. 3. On 3/17/2022 current staff, to include Nurses and Nurse Aides, housekeeping/laundry, dietary, therapy and all department heads were re-educated on the abuse policy to include any employee or contracted service provider who witnesses or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, to a resident, is obligated to report such information immediately to the Administrator and to other officials in accordance with State law. The facility is expected to report to DHSR no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. In the absence of the Administrator, the Director of Nursing is the designated abuse coordinator. Education also included if a resident is combative make sure that the resident is safe and walk away. Do not initiate physical contact if the resident's behavior is escalating. Touching can trigger violence in some. Provide time for the resident to calm down and re-approach. Employees are trained to protect residents from abuse at all times, including intervening with said abuse if they witness it. Notify police if additional assistance is needed. All new staff will be educated upon hire during orientation. All staff were educated on 3/17/2022 or prior to their next shift. The education was provided by the Director of Nursing. 4. Residents will be asked at least three times weekly for 12 weeks during daily rounds of the department heads; has any staff member mistreated/abuse/neglect you since you have been a resident here? Has any staff member taken or misused your property since you have been a resident here? Are you fearful of any staff member while residing here? Do you know who to report abuse to? Are you fearful of retaliation for reporting abuse/neglect? The department head will report findings to the Administrator and/or designee in stand down meeting, daily times five per week. 5. The Administrator is responsible for implementing this plan. Findings will be reviewed by QAPI committee monthly and Quality monitoring (audit) updated if changes are needed based on findings. The Quality Assurance Performance Improvement Committee consists of but not limited to the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Manager, Social Services Manager, Business Office Manager, Activities Director, Human Resources, Pharmacist, Medical Director, Certified Nurse Aide, Dietary Manager, Maintenance Director, Housekeeping Supervisor, Admissions, Medical Records, and MDS Nurse. Results of audits will be reported to Quality Assurance Performance Improvement Committee monthly for three months. Allegation of Compliance 3/31/2022 The Corrective Action plan was validated on 5/26/2022 and concluded the facility had implemented an acceptable corrective action plan on 4/21/2022. Interviews with current nursing staff including agency staff revealed the facility had provided education and training on abuse, notify supervisor immediately, ensure resident is safe and the Administrator is Abuse Coordinator. The audits conducted starting on 3/30/2022 revealed residents were asked about abuse and if they had been abused. Skin checks were completed for all non-alert and oriented Residents by 3/17/2022.The audits continued weekly through the validation date. On 5/26/2022 there was sufficient evidence to support the Facility's Corrective Action Plan was implemented and carried out by 3/31/2022.

Based on record review, resident, staff, Psychologist, Nurse Practitioner, and Medical Director interviews the facility failed to: 1) assess a resident's [CONDITION(S)] and suicide attempt to determine underlying causes, 2) document a suicide attempt and communicate the attempt with the resident's behavioral health provider to coordinate care, and 3) develop a plan of care with individualized care approaches and provide ongoing assessment of the care approaches to ensure resident's psychiatric health needs were being met for 1 of 1 resident reviewed for behavioral health services (Resident #36) who reported suicide ideations on [DATE] and then acted upon her [CONDITION(S)] by placing a plastic bag over her head on [DATE] in an attempt to suffocate herself. The immediate jeopardy began on [DATE] when Resident #36 reported [CONDITION(S)] and the facility failed to develop and implement effective interventions. The immediate jeopardy was removed on [DATE] when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity (E no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education was in place and monitoring systems that were put into place were effective. The findings included: Resident #36 was admitted to the facility on [DATE] and recently readmitted to the facility on [DATE]. Resident #36's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #36 was moderately cognitively impaired and had no signs or symptoms of [CONDITION(S)]. The MDS further indicated that Resident #36 reported feeling down, depressed, or hopeless never to 1 day during the assessment reference period. Feeling bad about yourself or you are a failure, or you have let your family down 7 to 11 days and thoughts that you would be better off dead or thoughts of harming yourself never to 1 day during the assessment reference period. No behaviors or rejection of care was noted. Review of a care plan revised on [DATE] read in part, Resident #36 uses an antidepressant medication related to depression and [CONDITION(S)]. The goal read: the resident will be free from discomfort or adverse reactions related to antidepressant through the review date. The interventions included: administer antidepressant as ordered, monitor for side effects and effectiveness every shift, educate the resident/family about risk, benefits, and side effects, and improve sleep/wake cycle. Review of a nurse's note dated [DATE] at 5:08 PM read resident stated to hall nurse during shift that she was having [CONDITION(S)]. This nurse instructed hall nurse to ask resident if she had a plan. Resident stated to hall nurse that she did not have a plan and that she did not truly have [CONDITION(S)] at the present time, she was just depressed because she missed her family and wanted to go home and hated being in a facility. Signed by the former Director of Nursing (DON). Review of Resident #36's active care plan revealed no care plan that addressed Resident #36's [CONDITION(S)] on [DATE] and no care plan interventions that address how the staff should care for Resident #36 when she has [CONDITION(S)]. Attempts to speak to the former DON were made on [DATE] without success. Review of a nursing note dated [DATE] at 3:34 PM read in part, resident noted this morning with third shift nurse that she had [CONDITION(S)] wanting to place a plastic bag over her head. Patient stated the only thing that stopped her from following through is she made a promise to her son she would never try to do this again. This morning with this writer she denied any [CONDITION(S)] at this time. No reports all day she had those thoughts anymore. Signed by Nurse #7. Nurse #7 was interviewed on [DATE] at 10:16 AM. Nurse #7 confirmed that she no longer worked at the facility and stated her last day was sometime in [DATE]. Nurse #7 stated that she recalled the incident in [DATE] when Resident #36 had gotten upset at her family and stated she just did not want to live anymore and wanted to put a plastic bag over her head. Nurse #7 explained that she had a good relationship with Resident #36, and they spoke for a bit, and she seemed fine. She stated she did not recall reporting the suicide ideations to anyone or she would have documented it in the electronic medical record. Review of a Psychotherapy Progress note dated [DATE] read in part; Symptoms and Behaviors: Patient appeared anxious with anxious affect and negative verbalizations. Patient was seen in her room as she lay on her bed dressed in bedclothes. Discussed patient anxiety regarding fear of loss of support and increased vulnerability. Patient Reports and Progress Observed: Patient responded well to session. Patient has longstanding frustration with medical community and treatment and recommendations. The note was signed by the Psychologist. Review of Resident #36's electronic medical record and hard chart record revealed no documentation of Resident #36's suicide attempt on [DATE]. Review of an emergency room Physician note dated [DATE] read in part, patient presents to the emergency department for evaluation following a suicide attempt. It was reported that the patient was found at her nursing home after she attempted to place a bag over her head in attempt to kill herself. She reports this is no way to live and notes that she is depressed regarding her current health and living situation. The patient reports that she did try to kill herself by using a bag. She denied current suicidal ideation but stated she would not have been upset if she had died . The Disposition stated: Psychiatric hold. Recommended for inpatient admission. Review of the facility nursing schedule dated [DATE] indicated Nurse #7 was taking care of Resident #36 along with Nurse Aide (NA) #11 and NA #12. NA #11 was interviewed on [DATE] at 11:01 AM. NA #11 confirmed that she was working on [DATE] along with NA #12 and Nurse #7. She stated that before lunch she had been into provide incontinence care to Resident #36 and she asked for a trash bag, and I didn't have one at the time. She stated she told Resident #36 when she finished her round, she would bring her a bag and she exited the room. NA #11 stated that after she had exited Resident #36's room she had gone out to take her break before the lunch trays arrived in the unit. While she was on her break approximately ,d+[DATE] minutes after she had been in Resident #36's room, NA #12 came running outside and stated that Resident #36 had a bag over her head and I ran into her room. Resident #36 was in her bed with a clear trash bag over her head and she had it held tightly around her neck and under her chin. I ripped the bag off Resident #36 and NA #12 ran to get Nurse #7. NA #11 stated that when she got the bag ripped off Resident #36, she was pale and sweaty, and she stayed with her until Nurse #7 could get her ready to be sent out to the emergency room . Once Nurse #7 got her paperwork copied, she stayed in the room with her until the Emergency Medical Services (EMS) arrived to transport her to the hospital. She added she did not obtain any vital signs but stated Nurse #7 may have done that while she was in the room with her. NA #11 stated that she had never heard Resident #36 say anything about suicide before. An attempt to speak to NA #12 was made on [DATE] at 11:37 AM without success. Nurse #7 was interviewed on [DATE] at 10:16 AM. Nurse #7 stated that she was not aware of Resident #36's suicide attempt on [DATE] she stated, she did not do that while I was there. Review of Entry Tracking tool dated [DATE] indicated Resident #36 had readmitted to the facility from an acute care hospital. An interview was conducted with Resident #36 on [DATE] at 4:08 PM. Resident #36 stated that she recalled the events of [DATE] when she attempted to kill herself by placing plastic bag over her head. She could not recall where she got the plastic bag that day. She stated, I get overwhelmed of being sick and didn't know what to do. She stated she went to the hospital for a few days and came back. She stated she continued to have [CONDITION(S)] from time to time. Review of Psychiatry Follow Up Note dated [DATE] read in part; Chief Complaint: Patient seen for routine follow up, she still does not like her roommate. Who is always crying and moaning day and night. Resident history of attempted suicide four times by overdose-last event in 1983. History of Present Illness: Resident #36 is alert and oriented and very pleasant. She is seen today for establish chronic problems with moderate depression/anxiety/[CONDITION(S)]. Discussed case with staff today at a gradual dose reduction of her medicine is not recommended. She denies any thoughts of suicidal ideation, homicidal ideations, paranoia, or delusion. Findings: [CONDITION(S)] disorder-stable, anxiety/depression: intermittently unstable. The note was signed by the Certified Physician Assistant. Attempts to speak to Certified Physician Assistant were made on [DATE] and [DATE] and were not successful. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed that Resident #36 was cognitively intact. The MDS also revealed that Resident #36 reported feeling down or depressed and thoughts you would be better off dead or thoughts of harming yourself never to 1 day during the assessment reference period. Review of Resident #36's active care plan revealed no care plan that addressed Resident #36's [CONDITION(S)] and attempt on [DATE] and no care plan interventions that address how the staff should care for Resident #36 when she has [CONDITION(S)]. Resident #36 was interviewed on [DATE] at 12:09 PM. She asked if this state had physician assisted suicide and was told no. When asked if she was interested in that she replied, yes this is not living. Resident #36 denied any [CONDITION(S)] currently but stated she had them in the past. Review of a nurses note dated [DATE] at 12:34 PM read in part, resident expressed to the nurse aide that she did not want to be in this world anymore, expressed same thing to nurse. Told Assistant Director of Nursing and called Emergency Medical Services. Four person assist from bed to stretcher. Resident sent out at 12:05 PM. Review of emergency room note dated [DATE] read in part, patient wanting evaluation for [CONDITION(S)] without a plan and depression. Patient reports that she would be better off dead and has a decreased quality of life and spends most of her day in bed and she think this is contributing to her depression. The patient is endorsing suicidal ideation but reports she does not know how she would end her life at this time. She does have a history of suicide attempt in her past. No new prescriptions were indicated, and the resident was instructed to contact her primary care physician in 1 to 2 days for follow up. Resident #36 was discharged back to the facility on [DATE]. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Psychologist was interviewed on [DATE] at 2:29 PM and reported he visited with Resident #36 every week or two. He stated she had some chronic illness that caused her a great deal of stress and anxiety. He added she had a long history of [CONDITION(S)] and attempts in her past. The Psychologist stated that Resident #36 had not reported any [CONDITION(S)] in some time and went on to say that he was not aware of her suicide attempt on [DATE] and stated, I really wish she would have expressed that to me so I could have gotten down to what the problem or issue was. The Psychologist stated that had he been aware Resident #36 would have been first on his list to see and would have asked another member of the mental health team to review her medication because maybe they were just not working for her anymore. The Psychologist added that the staff (including him) needed to work on engaging Resident #36 into the life of the facility or into her family's life and bring her more hope. He stated that he tried to help her understand the value she brought to her family. Her biggest stressor right now was the health of her husband and how he was not able to visit as often due to his declining health. He stated that each time he came to the facility he spoke with the staff to find out how Resident #36 was doing which was very important for him to know before going to into her room. The more information the staff could provide to him the better he was able to help and direct Resident #36's session. The Psychologist stated that he had seen Resident #36 on [DATE] and was not aware that after his visit she had [CONDITION(S)] and had to return to the emergency room . He stated he wished Resident #36 would have shared with him her thoughts during the session on [DATE] and he could have helped her work through them. The Nurse Practitioner (NP) was interviewed on [DATE] at 12:40 PM. The NP stated she was aware of Resident #36's suicide attempts in the past and was made aware of her attempt to kill herself on [DATE]. The NP stated she previously met with her family and learned that Resident #36 had mental health issues for as long as the family could remember. The family reported that Resident #36 preferred to take medications then sleep the days away. The NP stated that in addition to Resident #36's [CONDITION(S)] and suicide attempt she has some Post Traumatic Stress Disorder and [CONDITION(S)] disorder and was followed by the mental health team that came to the facility. She was aware that when Resident #36 attempted suicide on [DATE] they sent her to the emergency room and the nursing staff should have notified the mental health team of her attempt. She further stated that on [DATE] Resident #36 again endorsed [CONDITION(S)] and was sent to the emergency room . When she got there, she stated it was a passive thought and she had no plan to act upon it. She reported she saw and evaluated Resident #36 on [DATE] when she returned from the emergency room , and she denied any [CONDITION(S)] at that time. The Medical Director (MD) was interviewed on [DATE] at 1:48 PM. He confirmed he was aware of Resident #36's [CONDITION(S)] and suicide attempt that required her to be sent to the emergency room and nothing came of it. The MD indicated staff should use nursing judgment when working with Resident #36 and stated it was not important for the staff to be educated on her condition or history. The MD stated he would expect the staff to notify the mental health professional of her attempt and he would expect for the event to be documented in her medical record. The Interim Director of Nursing (DON) was interviewed on [DATE] at 4:07 PM. The DON stated she only knew what she had been told about Resident #36's attempted suicide which was that she went to the emergency room , and they kept her for a few days, and she returned. The DON confirmed that there was no change in condition or documentation about the event, and she had reached out to the previous DON to see if she knew anything but was unable to reach her. If someone reported that they were suicidal they should immediately be sent out and evaluated by the mental health team to determine if they were safe. The staff should then complete the change in condition and/or a progress note along with notifying the family and medical provider. They should also reach out to the mental health team that came to the facility to let them know. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 9:39 AM. The facility provided the following IJ removal plan: *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Residents who express [CONDITION(S)], with or without a plan, have the potential to be affected by this deficient practice: - A review of Resident #36's medical record revealed that on [DATE] Resident #36 reported to Nurse #7 that she had [CONDITION(S)]. She was transferred to the hospital on [DATE] for evaluation of a suicide attempt. Resident returned to the facility on [DATE]. Resident was cleared by acute care hospital of [CONDITION(S)]. Resident was seen by the facility Nurse Practitioner on [DATE] and agreed that resident was no longer suicidal and to continue her current anti-depressant and anti-psychotic medications. - Resident #36 was sent to the emergency room (ER) on [DATE] for evaluation of [CONDITION(S)]. Resident returned that same day with no new orders and as ER stated that she was no longer expressing [CONDITION(S)]. - Resident #36's care plan has been reviewed and updated to include a history of [CONDITION(S)] and attempts by the Minimum Data Set (MDS) nurse on [DATE]. Resident continues to be seen by the Psychiatrist bi-weekly and by the Psychologist weekly or on a as needed basis as deemed necessary by said Psychologist. Resident #36's room has been inspected by the Assistant Director of Nursing on [DATE] and again on [DATE] to ensure that no plastic bags are present or other items that resident could use to harm herself are present. - On [DATE] the Social Services Director documented in the medical record that she contacted the Psychologist on [DATE] and [DATE] regarding the history of Resident #36's [CONDITION(S)] and attempts including [DATE], [DATE], [DATE], and [DATE]. - Staff have been in serviced on the risk of plastic bags to Resident #36 by the Divisional Director of Nursing on [DATE]. This had resulted in heightened awareness for staff or need to be diligent regarding Resident #36's access to plastic bags. - Licensed staff was educated on [DATE] to notify the Director of Nursing immediately of [CONDITION(S)] so that the Director of Nursing can make sure the Psych services is made aware. - Residents with a Brief Interview for Mental Status (BIMS) score greater than or equal to 8 will be interviewed by the Director of Nursing, Assistant Director of Nursing, Unit Manager, or Social Services Director on [DATE] for thoughts of suicide. If any residents are identified as suicidal staff will immediately initiate the suicide protocols per policy and procedure as follows: 1. Staff to remain with resident until a Physician or a qualified Psychologist evaluate the resident and document that the resident is not suicidal or at risk of harming self or until the resident is transferred to a higher level of care. 2. The nurse is to be notified immediately. 3. The nurse is to notify the Physician and Responsible Party of the resident's condition. 4. The nurse is to notify the Director of Clinical Services and the Executive Director. 5. The nurse is to prepare the resident for transfer and ensure a safe transfer to the emergency room if ordered. * Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome form occurring or recurring, and when the action will be complete. - All facility staff, to include all contract staff, which includes housekeeping, dietary, and rehab services were educated on [DATE] by the Divisional Director of Nursing that Resident #36 is to have no plastic bags in her room due to a history of suicidal attempts using a plastic bag. This has resulted in a heightened awareness for staff of need to be diligent regarding Resident #36's access to plastic bags. - Licensed staff was educated on [DATE] to notify the Director of Nursing immediately of [CONDITION(S)] so the Director of Nursing can make sure psych services is made aware. - Facility staff has been educated by the Divisional Director of Nursing by [DATE] on the policy and procedure related to resident expressing [CONDITION(S)]. The assessment, PHQ-9, used to evaluate the residents is approved by CMS to be administered by long term care Social Services personnel as well as any licensed nursing staff. - Divisional Director of Nursing will re-educate all staff on policy, Resident Expressing [CONDITION(S)] on [DATE]. Any staff not scheduled to work on [DATE] must complete education prior to working their next shift. - The Divisional Director of Nursing will ensure that all staff review education, which includes the policy and procedure related to Resident Expressing [CONDITION(S)], via paper handout, in person. Quiz will be administered after training to ensure that each staff member understands their responsibility and the steps to take if a resident expresses [CONDITION(S)]. - The Divisional Executive Director of Nursing will re-educate licensed staff on the need to thoroughly and accurately document all resident expression of [CONDITION(S)] and the care plans regarding resident who are identified as being at risk for [CONDITION(S)] by [DATE]. Any staff not scheduled to work on [DATE] must complete education prior to working their next shift. Alleged IJ removal date is [DATE]. A credible allegation validation of mental health services was conducted in the facility on [DATE]. Record review included Resident #36's care plan which was noted to have been initiated and included interventions to reduce the risk of self-harm for example no plastic bags were to be in Resident #36's reach. The in-service training records indicated that all staff including agency, nursing, housekeeping, dietary, therapy, and administrative staff had been educated on the facility's policy and procedure for residents who had [CONDITION(S)] which included staying with the resident until assessed by the Psychologist or Medical Doctor or being transferred to a high level of care. Immediately notifying the nurse, Director of Nursing and Administrator to ensure that the mental health professional was also made aware and ensuring that the resident's environment had nothing that could be used for self-harm. Interview with staff that included administrative, dietary, housekeeping, therapy, and nursing all revealed that they had received the education on the facility policy and procedure for resident with [CONDITION(S)] and were aware how to respond appropriately if a resident endorsed [CONDITION(S)]. Finally, Resident #36 was observed resting in bed and was alert and verbal. She was smiling and reported that the staff were taking good care of her. There no plastic bags noted in her room or in the trash cans that were beside her bed and at the door. The corded call bell had been replaced with a hand bell to which Resident #36 demonstrated appropriate use of. The facility's IJ removal date of [DATE] was validated and an extended survey was conducted.

Based on observation, record review, staff, Nurse Practitioner, and Psychologist interview the facility failed to treat a resident in a dignified manner by segregating her from having a compatible roommate based on the residents COVID-19 vaccination status (Resident #55). The facility also failed to remove a female resident's facial hair causing her to be embarrassed for 2 of 6 residents reviewed for dignity (Resident #59) . The findings included: 1. Resident #55 was readmitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #55 was cognitively intact and had no signs of [CONDITION(S)]. The MDS further indicated that Resident #55 had little interest or pleasure in doing things 2 to 6 days, feeling down, depressed, or hopeless 2 to 6 days and feeling tired or having little energy 2 to 6 days during the assessment reference period. An observation and interview were conducted with Resident #55 on 02/28/22 at 3:27 PM. Resident #55 was resting in bed in the last room on the hallway. Resident #55 resided in the bed near the window and the curtain between the two beds was pulled and Resident #55 could not see into the hallway. She was resting in bed with both hands contracted. Resident #55 explained that when she readmitted from the hospital, she was told by the staff that she could only room with 3 other female residents in the facility because she was unvaccinated against COVID-19. Resident #55 explained that 2 of the 3 other females in the facility that were also unvaccinated against COVID-19 were nonverbal and she had roomed with 2 of them and neither of them could talk with her. She began to tear up and stated over and over again I crave adult conversation she stated that she saw no one except for the few minutes that the staff were in her room delivering her meal tray or when they came to provide care. She stated, I feel neglected and like I am not supposed to ask for help like they put me in this room and forgot about me. During the observation the Wound Nurse (WN) and Nurse #6 came into the room to perform wound care. While Resident #55 was turned on her side towards Nurse #6 she stated to Nurse #6 I crave adult conversation and again began to cry. Nurse #6 acknowledged Resident #55 had spoken to her and rubbed her shoulder but did not respond to her words. The Social Worker (SW) was interviewed on 03/02/22 at 10:20 AM. The SW stated that Resident #55 was only able to room with other COVID-19 non-vaccinated residents and they only had 3 other females that she could room with. The SW stated that Resident #55's current roommate was non-verbal as was her previous roommate. The SW could not recall if she had ever heard Resident #55 say that she was lonely, but she was aware that she saw the Psychologist when he came to the facility. The Activity Assistant (AA) was interviewed on 03/02/22 at 11:13 AM. The AA stated that she performed one on one activities with Resident #55 weekly. She stated that she had spent 10-15 minutes yesterday talking with her. The AA stated that Resident #55 tells me all the time that she wants someone to talk too. The AA stated the facility only allowed Resident #55 to room with other COVID-19 non-vaccinated residents which really limited the roommates that she could have. The Psychologist was interviewed on 03/02/22 at 3:06 PM. He reported that he visited with Resident #55 every week or two. He stated that Resident #55 had no support system outside of the facility staff and himself. He stated she was estranged from what family she had and the one friend she had passed away. He added that Resident #55 responded to things out of panic and felt as though she was a burden to people and that every time, he spoke to her she expressed how lonely she was and how much she craved adult conversation. The Psychologist stated that he believed it would benefit Resident #55 to be in a room with someone that could talk with her and whom she could connect with. He added that Resident #55 has told him that there were only 3 other female residents that she could room with due to her COVID-19 vaccination status. He added that when the staff came into Resident #55's room she attempted to monopolize their time because she felt like she would not get the opportunity to talk to anyone else for a long period of time, again all out of panic. Nurse Aide (NA) #5 was interviewed on 03/03/22 at 8:11 AM. NA #5 stated she was familiar with Resident #55 and took care of her often. She stated that Resident #55 has on numerous occasions told her that she was lonely but stated it was hard to spend any time with her because I am running two halls. NA #5 stated she could not recall if she had reported to anyone Resident #55's feeling of loneliness or not. The Nurse Practitioner (NP) was interviewed on 03/03/22 at 1:04 PM. The NP stated that when she visited with Resident #55, she always wanted to talk for a long period of time. She stated, I would imagine she is lonely, she is very alert and cognitively intact and staff were busy, and they have big workloads. The NP stated that a more appropriate roommate would help Resident #55's mental health and feelings of loneliness. NA #6 was interviewed on 03/03/22 at 2:34 PM. NA #6 stated that she was familiar with Resident #55 and took care of her often. She stated that Resident #55 had frequently complained to her that she was lonely. Na #6 stated she tried to spend a few minutes with her and to comfort Resident #55 and to try and help her feel some better. NA #6 did not recall if she had ever reported Resident #55's loneliness to the nurse but she was sure at some point she probably had done so. The interim Director of Nursing (DON) was interviewed on 03/03/22 at 3:02 PM. The DON stated she had been interim since January 2022. The DON stated that she was aware that the unvaccinated residents were housed all together, but she was not aware where that direction came from. The DON explained that she was the interim Administrator at the facility until November and that was not the case when she was the Administrator. She stated that when she returned to the facility as the Interim DON in January all the unvaccinated COVID-19 residents were housed together. The DON stated it would be very difficult to find a suitable roommate for Resident #55 but that was something that they could work on. The Corporate Clinical Nurse (CCN) was interviewed on 03/03/22 at 3:31 PM. The CCN stated that he was not sure where the rule came from but that he did not necessarily disagree with it. He stated that they could work on finding a more suitable roommate for Resident #55 and added that they followed the Center for Disease Control and Prevention when making room assignments. 2. Resident #59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was cognitively intact and had no behaviors of rejection of care. The MDS indicated the Resident was coded for a 7 (activity occurred only once or twice) for personal hygiene with 2 plus staff assistance and she had functional limitation in range of motion of her upper extremity on both sides. On 02/28/22 at 11:26 AM an interview and observation were made of Resident #59 who was lying in bed. The Resident was observed to have dark facial hair above her upper lip and chin approximately half an inch long. The Resident explained that she needed assistance with shaving because she had Parkinson disease and could not use her hand to shave herself. The Resident continued explain that she was supposed to be shaved during her showers on Monday and Thursday evenings, but she had not had a shower in 6 weeks. Resident #59 stated she did not like the facial hair, and it embarrassed her to have it. An interview was conducted with Nurse Aide (NA) #7 on 03/02/22 at 4:45 PM who confirmed that she was scheduled to work with Resident #59 on second shift on 02/28/22. The NA explained that she offered to give Resident #59 a shower around 11:00 PM but the Resident did not want a shower that late. The NA stated shaving should be completed during the residents' showers. The NA could not comment about if she noticed facial hair on Resident #59 on 02/28/22. During an observation of Resident #59 on 03/02/22 at 5:19 PM the Resident was sleeping and clean shaven. Attempts were made to interview Nurse Aide #9 who worked with Resident #59 on 02/14/22 and Nurse Aide #10 who worked with the Resident on 02/24/22 but the attempts were unsuccessful. During an interview with the Director of Nursing (DON) on 03/03/22 at 5:32 PM the DON indicated Resident #59 should have been shaved when her facial hairs were obvious.

Based on observations, record review, staff, resident, Rehabilitation Director and Nurse Practitioner interviews, the facility failed to prevent a contracture from worsening for 1 of 2 residents reviewed for range of motion (Resident #34). Resident #34's left shoulder and elbow were more contracted with less range of motion. The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a picture in Resident #34's electronic record taken shortly after admission showed Resident #34 sitting up in a wheelchair with her left upper extremity resting in natural position laying at her waist. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #34 was cognitively intact and required extensive assistance with activities of daily living. The MDS further indicated that there was no impairment to Resident #34's upper or lower extremities. Review of an Occupational Therapy Discharge Summary dated 10/27/21 indicated the following goals for Resident #34: 1. Patient will safely perform upper dressing routine unsupported at edge of bed with minimal assistance with verbal cues based on improved strength, tone/motor control, static sitting balance, dynamic sitting balance, functional activity tolerance and coordination. At the beginning of treatment Resident #34 required moderate assistance and the end of therapy she required moderate assistance. 2. Patient will perform all bed mobility task with minimal assistance with verbal cues and compensatory strategies in order to participate in edge of bed activities, prepare for transfers, participate in activities of daily living and participate in self-care activities. At the beginning of treatment Resident #34 required moderate assistance and the end of treatment required maximal assistance. 3. Patient will complete transfers with minimal assistance with verbal cues, compensatory strategies and adaptive/assistive devices in order in to participate in activities of daily living. At the beginning of treatment Resident #34 required maximal assistance and at the end treatment required maximal assistance. 4. Patient will demonstrate improved sustained sitting balance for activities of daily living to moderate impairment for 10 minutes in order to complete bilateral upper extremity exercise, therapeutic exercise and functional task to increase independence with activities of daily living and functional mobility. At the beginning of treatment Resident #34 was noted to have severe impairment and at the end of treatment was noted to have moderate impairment. Review of functional maintenance plan for Resident #34 dated 10/21/21 read in part, passive range of motion to left upper extremity to reduce tone, inhibit contracture development and prepare for splitting. The plan was signed by Occupational Therapy Assistant (OTA). The Occupational Therapy Discharge Summary dated 10/27/21 indicated the Resident was being discharged from therapy and all goals had been met. Review of an Interdisciplinary Therapy Screen dated 01/03/22 indicated that Resident #34 had no changes during the quarter and no therapy was recommended. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #34 was cognitively intact and required extensive assistance with activities of daily living. The MDS further indicated that Resident #34 had an impairment to one upper and lower extremity and indicated that no therapy or restorative program was in place during the assessment reference period. An observation and interview were conducted with Resident #34 on 02/28/22 at 10:15 AM. Resident #34 was resting in bed. Her left arm was contracted up to her chest area and her left hand rested just below her chin. Resident #34 stated that she had a stroke and that was why her left arm was contracted. She stated that she had a splint but she could not get anyone to put it on her. She stated she would wear the splint for as long as she could stand it, but she couldn't get the staff to put it on her. Resident #34 was asked if she could relax her left arm and she attempted to do so but could not relax her arm, she even tried pulling the arm with her right hand and could not do so. An observation of Resident #34's room revealed a hand splint laying on top of shoe box on top of her wardrobe. Resident #34 confirmed that was her splint. An interview with the OTA was conducted on 03/01/22 at 3:51 PM. The OTA confirmed that he had treated Resident #34 in October 2021 for activities of daily living and splinting. He stated that she came to the facility from the hospital with a splint that she was wearing and was tolerating it for 2-3 hours at a time. He explained that when it came time to discharge Resident #34 from Occupational Therapy the facility did not have a restorative program, so she was discharged with a functional maintenance program which was a program that was established for nursing staff to continue with range of motion. The Activity Director (AD) was interviewed on 03/02/22. The AD reported that Resident #34 was a family member of hers and confirmed that she had a hand splint when she first came to the facility but here lately I have not seen it. The AD stated that Resident #34 would call her to come and put the splint on her, but she could not recall the last time she applied the splint but stated it had been longer than a month. Nurse Aide (NA) #5 was interviewed on 03/03/22 at 8:11 AM. NA #5 confirmed that she was familiar with Resident #34 and took care of her often. NA #5 stated that Resident #34 had no splint that she knows of but stated that Resident #34 reported to her that her left arm was so tight that it was actually hurting her breast area. NA #5 stated that she attempted to put a washcloth in the bend of her elbow to help ease the discomfort. NA #5 stated that in the last several weeks her arm has gotten so tight she is not able to open it at all. She stated that she had not reported that to anyone because she did not really know what Resident #34's baseline was and what the process for reporting was at the facility. NA #6 was interviewed on 03/03/22 at 2:36 PM. NA #6 confirmed that she was familiar with and took care of Resident #34 often. She stated that she had never seen or applied a splint to Resident #34. NA #6 stated that Resident #34's left arm was tighter then when she first admitted to the facility, and it was more drawn up. She stated getting Resident #34 dressed was doable but was difficult because her arm was so tight. NA #6 stated she had not reported the issue because she was not sure how that process worked. An observation of Resident #34 was made on 03/03/22 at 10:41 AM along with the OTA. The OTA began to attempt to move Resident #34's left arm and stated that her left elbow and shoulder are much tighter with less range of motion. The OTA stated that there was not much change with her hand but there were changes with her elbow and shoulder area. The OTA stated that Resident #34 needed to be re-evaluated. The OTA stated that during the time he treated her in October 2021 he could ask Resident #34 to relax her arm and she could do so but Resident #34 was unable to do that when asked by the OTA. The OTA further stated that when Resident #34 was discharged from Occupational Therapy in October 2021 she had not met her goals. She was planning on discharging home but for some reason that did not happen. The Director of Rehab (DOR) was interviewed on 03/03/22 at 10:51 AM. The DOR stated that most residents were screened quarterly, and she created the list of required screens using the Minimum Data Set schedule to determine which residents required a therapy screen. The DOR explained that when Resident #34 was screened in January 2022 it was done by the Physical Therapy Assistant (PTA) and stated she was not able to touch the resident to assess her contracture. The screen would have consisted of a verbal exchange from staff about Resident #34 and a visual observation of Resident #34. The DOR stated that no one had reported any changes with Resident #34. Staff had been asked to apply her splint and Resident #34 should not have to ask for her splint to be applied. She added that normally the splint would be applied and worn as tolerated, normally we train the nursing staff to apply the splint, and normally we have the nursing staff sign the education sheet but that did not happen because we thought Resident #34 was discharging home. The DOR stated that they could have resumed her therapy when Resident #34 stayed in the facility but could not explain why that did not happen or why her services were abruptly stopped. The Nurse Practitioner (NP) was interviewed on 03/03/22 at 12:57 PM. The NP stated that at some point Resident #34 had a splint but that it was missing, and they were trying to determine how to replace the splint. The NP stated that a splint would have prevented the contracture from getting worse or tighter. The interim Director of Nursing (DON) was interviewed on 03/03/22 at 4:30 PM. The DON stated that what she had been told about Resident #34 was that she wore the splint when she wanted to for an hour at a time. She stated that if the staff noted a change or decline, they should have done a therapy referral. The DON stated she would expect the staff to notify therapy if Resident #34's contracture was getting worse or if she had any change in her mobility.

Based on record review and interviews with the Legal Guardian (LG), resident, staff, and the Nurse Practitioner (NP), the facility failed to follow instructions from the LG and allowed Resident #1 to leave the facility with an unauthorized person. Resident #1 was later diagnosed with aspiration pneumonia. This situation affected 1 of 3 residents reviewed for accidents. Immediate Jeopardy began when Resident #1 was signed out of the facility on 8/14/21 without consent from the LG. Immediate Jeopardy was removed on 8/21/21 when the facility provided and implemented an acceptable credible allegation for removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not IJ) to complete education and ensure monitoring systems put into place were effective. The findings included: Resident #1 was admitted to the facility on [DATE] with the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the court document issued by the State of North Carolina titled; Letters of Appointment Guardian of the Person named Resident #1 as being an incompetent person and appointed guardianship to the local Department of Social Services (DSS) on 5/20/21. Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -A diet order for nothing by mouth (NPO) written on 6/7/21. -Enteral feed (intake of nutrition via gastrointestinal tract) five times a day give tube feeding bolus via syringe written on 6/7/21. Review of the Minimum Data Set (MDS) dated [DATE] assessed Resident #1 cognition as being moderately impaired for making daily decisions. He required extensive assistance with eating and received 51% or greater of his calories and 501 milliliters or greater of fluids through a feeding tube. The care plan revised on 6/23/21 identified Resident #1 required tube feedings related to dysphagia, infection, and pneumonia. The goal was for Resident #1 to remain free of side effects or complications related to tube feedings through the review date. Interventions in place included listen to lung sounds as needed and monitor, document, and report as needed any signs or symptoms of aspiration. Review of the facility sign-out records revealed on 8/14/21 at 10:45 AM Resident #1 was signed out of the facility with Friend #1 who was not authorized by the LG. During an interview on 8/18/21 at 2:31 PM the LG revealed she came to the facility for a visit with Resident #1 on 8/13/21. The LG had a conversation with Resident #1 and the Social Worker (SW) stating she made it clear to both Resident #1 was not to leave the facility with anyone except DSS personnel and could not attend the festival on 8/14/21. The LG discussed her concerns related to Resident #1's history of unsafe decisions that compromised his health. On 8/16/21 the LG received information Resident #1 left the facility with an unauthorized person and had been seen by a Family Member (FM) and the Chief of Police unsupervised and eating and drinking at the festival on 8/14/21. On 8/16/21 the LG called the facility and spoke with the Administrator telling her Resident #1 left the facility with a friend without the LG's knowledge and had been seen eating and drinking at the festival. The LG revealed the Administrator was not aware Resident #1 had left the faciity on [DATE]. An interview was conducted on 8/18/21 at 10:59 AM with Resident #1. Resident #1 revealed on 8/14/21 he left the facility with Friend #1 to attend a festival. He left with Friend #1 that morning and returned the same day after it was dark. Resident #1 knew he had an appointed LG but denied she came to see him on 8/13/21. Resident #1 also denied his LG told him he couldn't leave the facility with an unauthorized person or could not attend the festival on 8/14/21. During the interview Resident #1 asked for some water to drink several times before he shared, he wasn't allowed to eat or drink by mouth and had a feeding tube. Resident #1 denied he ate or drank anything when at the festival and stated the people that said he did were not telling the truth. During an interview on 8/20/21 at 8:15 AM Friend #1 confirmed he was the person who signed out and took Resident #1 to the festival on 8/14/21. Resident #1 had called and asked if he would take him to the festival and he was aware Resident #1 was deemed incompetent and assigned a court appointed LG but had no knowledge he wasn't allowed to take Resident #1 out of the facility. On 8/14/21 Friend #1 picked up Resident #1 and was assisted by a male staff member with signing out while a female staff got Resident #1 ready to leave. Friend #1 revealed he was not given any medications or means to hydrate Resident #1 during the time they spent together. Friend #1 denied Resident #1 was left alone at any time they were together but a person at the festival did give Resident #1 a bottle of water which he did take a sip of. Friend #1 revealed he was able to get the bottle of water away from Resident #1 before he drank anymore and denied Resident #1 had anything else to eat or drink. Resident #1 and Friend #1 left the facility around 10:30 AM and returned the same day around 9:00 PM. Friend #1 stated he was told by facility staff not to let Resident #1 have anything to eat or drink by mouth and indicated he was already aware of this. Attempts to identify and interview the male staff who assisted signing Resident #1 out of the facility were unsuccessful. An interview was conducted on 8/18/21 at 3:04 PM with the FM of Resident #1. The FM revealed he attended the same festival on 8/14/21 and saw Resident #1 there. The FM revealed Resident #1 was walking from a building that served beer, soda, and food and was holding a cup containing a liquid in one hand and what appeared to be bread in the other and appeared to be alone. The FM did not interact with Resident #1 but did observe him for approximately 5 minutes and stated he did not see Resident #1 eat or drink. The FM did notify Resident #1's LG but did not contact the facility. An interview was conducted on 8/23/21 at 2:31 PM with the Chief of Police (COP). The COP revealed he received information from others that Resident #1 was with Friend #1 and was drinking at the festival on 8/14/21. The COP revealed when he saw Resident #1, he was standing outside a local restaurant and appeared to be alone and did not have any food or drinks nor did the COP see him consume any. The COP couldn't recall the names of the persons who informed him Resident #1 was drinking at the festival. An interview was conducted with Director of Nursing (DON) on 8/18/21 at 12:17 PM. The DON revealed Resident #1 asked about going to a festival and during their Department Head (DH) meeting on 8/13/21 they discussed concerns related to safety and him having a feeding tube and a diet order for NPO. A decision was made to let Resident #1 attend the festival and leave the facility on 8/14/21 and the SW was to contact the LG. During the DON's shift on 8/14/21 she was informed someone was at the facility to pick up Resident #1 and the last information she heard it was okay, so she approved he could leave the facility. The DON revealed she was not aware Resident #1's LG visited on 8/13/21 and instructed the SW he could not leave the facility with an unauthorized person or attend the festival and she was not made aware of this information until 8/16/21 when the Administrator told her about the phone call from the LG. An interview was conducted on 8/18/21 at 11:18 AM with the SW. The SW explained on 8/13/21 she was told to speak with Resident #1's LG about his request to go to a festival. Resident #1's LG told the SW and Resident #1 he could not leave the facility unless with another DSS worker. The SW revealed she also stated this information during their DH meeting on 8/13/21 but did not recall who attended but did tell the Assistant Director of Nursing (ADON). An interview was conducted on 8/18/21 at 11:57 AM with the ADON. The ADON revealed she was not told face to face by the SW Resident #1 was not to leave the facility. The ADON revealed she understood when a resident had a LG, they cannot leave the facility without first notifying the LG. The ADON revealed she knew notes were posted on 8/13/21 telling staff not to let Resident #1 leave the facility. An interview was conducted on 8/18/21 at 5:08 PM with the SW. The SW revealed she was present during the DH meeting on 8/13/21 and asked to notify the LG Resident #1 wanted to attend a festival on 8/14/21. The SW revealed before she was able to contact Resident #1's LG the LG came to facility for a visit on 8/13/21. The SW explained she and the LG and Resident #1 were standing together when she heard the LG tell Resident #1 several times not to leave the facility and he could not go to the festival on 8/14/21. The SW stated she wrote a note in Resident #1's chart and made a sign to put in a book kept on the medication cart for nurses to access related to resident information and taped a note at the nurse station for nurses to see stating Resident #1 could not leave the facility with anyone other than DSS personnel or facility staff. An interview was conducted on 8/19/21 at 11:18 AM with Med Aide (MA) #1 scheduled to work on 8/13/21 from 6:45 AM to 11:15 PM. MA #1 stated she did receive a note Resident #1 was only allowed to go out of the facility with his LG on 8/13/21 and stated the note was kept in the 24-hour nurse book at the nurse station. MA #1 also stated she did tell the oncoming nurse but could not recall who that was. During an interview on 8/19/21 at 10:47 AM Nurse #1 revealed she was responsible for the care of Resident #1 on 8/14/21 the day Friend #1 took him out of the facility. Nurse #1 revealed she was not told Resident #1 was deemed incompetent to make his own decisions nor aware he was appointed a LG. Nurse #1 revealed she did have access to Resident #1's medical record but didn't review before letting him leave the facility with someone she assumed was a family member nor did she notify the LG. Nurse #1 was aware Resident #1 was not allowed to have anything by mouth and if he ate or drank would be at risk for aspiration, but she didn't recall informing Friend #1 that information. Nurse #1 explained she should've reviewed Resident #1's medical records and notified his LG to ensure he was safe to leave the facility. Nurse #1 stated she was not told by anyone nor did she see any type of note Resident #1 was not to leave the facility with no one other than his LG. During an interview on 8/20/21 at 10:48 AM Nurse #2 explained he was responsible for the care of Resident #1 on 8/14/21 when he returned to the facility around 9 PM. Nurse #2 did not speak to Friend #1 nor question Resident #1 about ingesting food or fluids. Nurse #2 revealed he wasn't told by anyone Resident #1 was not allowed to leave the facility except with his LG nor did Nurse #2 see any notes stating that information. Nurse #2 stated 8/19/21 was the first time he was notified Resident #1 could not leave the facility with anyone other than his LG and asked to sign a paper stating Resident #1 had to have 2 facility staff or 1 facility staff and a DSS Guardian with him if he left the facility. An interview was conducted on 8/19/21 at 12:09 PM with Nurse #5 who was the oncoming nurse scheduled on 8/13/21 from 10:45 PM to 7:00 AM on 8/14/21. Nurse #5 was aware Resident #1 was strictly NPO with nutrition and medications administered via feeding tube and revealed Resident #1 was known to be non-compliant with being NPO and would sneak drinks of water. Nurse #5 stated she didn't know anything about Resident #1 being deemed incompetent or having a LG but was aware she could look that information up in Resident #1's medical record. Nurse #5 revealed she didn't know anything about Resident #1's LG giving instructions he could not leave the facility with an unauthorized person or attend the festival and stated she did not receive any information in report on 8/13/21 he could only leave the facility with DSS personnel. An interview was conducted on 8/18/21 at 4:38 PM with the DON. The DON revealed she was aware Resident #1 was deemed incompetent and assigned a LG. The DON revealed the LG should've been notified before Resident #1 left the facility and stated it was an oversight on her part. The DON revealed on 8/16/21 the Administrator made her aware Resident #1 was suspected of eating and drinking when at the festival which put him at risk for aspiration. The DON stated she performed an assessment for signs of aspiration and found nothing abnormal, so she did not inform the Nurse Practitioner (NP) on 8/16/21 and did not document her assessment. An interview was conducted on 8/18/21 at 4:52 PM with the Administrator. The Administrator revealed she became aware Resident #1 left facility with an unauthorized person when his LG called on 8/16/21 stating a FM saw Resident #1 eating and drinking at the festival. The Administrator told the LG she would investigate. The Administrator spoke with Resident #1 who confirmed had been out of building with a friend. The Administrator spoke with the SW who confirmed Resident #1's LG said he could not attend the festival during a visit on 8/13/21. The Administrator did not talk with Friend #1 who took Resident #1 to the festival. When the Administrator found out on 8/16/21, she asked the DON to assess Resident #1 but did not inform the NP. The Administrator revealed during their DH morning meeting on 8/13/21 it was agreed Resident #1 could attend the festival and stated the SW was to contact his LG. The Administrator did not tell Resident #1 he could go to the festival and was aware he was deemed incompetent by a court of law with an appointed LG. It was the Administrator's expectation the LG would've been notified before Resident #1 left the facility with someone other than the LG. On 8/18/21 at 11:44 AM a review of the note written by the SW revealed it was taped at the nurse's station and read in part, Attention Nursing Resident #1 cannot leave this building with anyone but his DSS guardian, or one of our staff members. He cannot make or receive any calls from Friend #1 per his Guardian. The note was signed by the SW and posted at the nurse's station with directions not to remove. There was no date on the note. An interview was conducted with the NP on 8/18/21 at 1:19 PM. The NP was aware Resident #1 was deemed incompetent and appointed a LG. The NP explained Resident #1 was NPO due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP was not aware Resident #1 left the facility without the LG's knowledge nor made aware by facility on 8/16/21 he was suspected of eating and drinking. The NP stated if the facility was aware Resident #1 was suspected of eating and drinking, she should have been notified and would expect nurse staff to listen to his lung sounds and obtain a full set of vital signs for at least 2 days and ask that the nurse put Resident #1 on her list of residents to see on her next visit for her own assessment. An interview was conducted with the NP on 8/20/21 at 10:00 AM. The NP assessed Resident #1 on 8/18/21 and revealed he was mildly tachycardiac (heart rate greater than 100) with minimal chest congestion and she ordered a chest x-ray. The NP received the chest x-ray results on 8/20/21 and explained the results showed bilateral pleural effusions (buildup of fluid in the space between the lungs and chest wall) meaning pneumonia was present in the lower lobes likely due to aspiration. The NP revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (antibiotic medication used to treat bacterial infections) 750 milligram (mg) give 1 tablet via peg tube one time only for pneumonia for day 1 to start on 8/20/21. -[MEDICATION(S)] (diuretic medication used to remove excess fluid from the body) 40 mg give 1 tablet via peg tube in the afternoon for pleural effusions for 3 days to start on 8/20/21. During a follow-up interview on 8/20/21 at 3:57 PM the NP could not say Resident #1 aspirated on 8/14/21 but stated there was a delay in notification he was suspected of ingesting food or fluids on 8/14/21. If notified on 8/16/21 the NP revealed she would have assessed Resident #1 at that time, and it was possible the delay in notification and treatment could have a negative outcome and Resident #1 could have become septic from having pneumonia. The Administrator was informed of immediate jeopardy on 8/20/21 at 9:28 PM. The facility provided the following acceptable immediate jeopardy removal plan with the correction date of 08/21/21. Identify those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the non-compliance. The Executive Director (ED) and Social Services (SS) Director identified 9 residents with legal guardians on 8-18-21 as those residents who are unable to make decisions for themselves regarding leaves of absence from the center. Current residents have been reviewed by the ED/SS Director on 8-18-21 to ensure that they have not been out on leave of absence without permission from their legal guardians. Also, current residents who have been out on Leave of Absence (LOA) in the past 5 days (since 8-14-21) were assessed by the Director of Nursing (DON)/Assistant Director of Nursing (ADON) on 8-18-21 to ensure no changes in condition, as a result. Residents on specialized diets were reviewed by the ED/DON/ADON on 8-18-21 to ensure consumption of approved diet, as ordered by the MD while out on LOA in the past 5 days (since 8-14-21). There were no additional changes in condition noted for other identified current residents, who had gone out on LOA from 8-14-21 through 8-18-21, requiring immediate notification to the MD by the Licensed Nurse for additional orders. Brief Summary of the allegation: Resident #1 was admitted to the facility on [DATE] with following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 court appointed guardian met with social worker at the facility on 8/13/21 to discuss that the resident had court appointed guardian and was not to not leave the facility with anyone other the DSS personnel. Family friend who accompanied him to a local festival signed Resident #1 out of the facility on 8/14/21 at 10:45 am. Resident #1 returned from the festival at approximately 9:00 pm on 8/14/21. Nurse #2 did not observe resident to have any signs of dehydration or sunburn. Nurse #2 checked resident's stomach for residual contents and there were none. Nurse #2 administrated a bolus tube feeding, per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/16/21 the court, appointed guardian called the facility and informed the administrator Resident#1 had left the faciity on [DATE] with a friend without her knowledge or consent with someone other than DSS personnel. The Legal Guardian revealed that multiple people at the festival had told her that the resident had been seen eating and drinking and appeared to be unsupervised. On 8/18/21, the Nurse Practitioner assessed resident, found resident to have mild [CONDITION(S)] with minimal chest congestion, and ordered a chest x ray. The Nurse Practitioner received the results of the chest x rays on 8/20/21 and determined that Resident #1 had bilateral pleural effusions in lungs. Resident #1 was then started on antibiotics. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 8-18-21, Regional Vice President of Operations (RVPO) educated Executive Director (ED) on legal guardians and residents' rights, as pertained to legal guardians. On 8-20-21 Executive Director educated the department managers, to include the Social Services Director, along with the nursing and ancillary staff members (including the receptionist), that Residents with Legal Guardians are unable to make decisions for themselves regarding medical and financial to include leaves of absence from the center. The resident's Legal Guardian will be notified for such medical, financial, and Leave of Absence requests. The approval for a Leave of Absence for a resident with a Legal Guardian will be witnessed by 2 staff members and noted in the resident's medical record. Disapproval by the resident's Legal Guardian for a requested leave of absence will also be witnessed by 2 staff members and documented in the resident's medical record. Additionally, the ED/SS Director has placed a notification in the electronic medical record, hard paper chart under the Demographics tab, as well as in the LOA sign out/sign in book (located at the receptionist's desk) to indicate that identified residents with a Legal Guardian are not to make medical, financial or leave of absence decisions without the notification to and consent from their Legal Guardians. Residents/Responsible Party, when going out on LOA, will be educated by the Licensed Nurse regarding their prescribed diets, to include specialized and therapeutic diets, along with their dietary restrictions to validate an understanding of what the resident can or cannot consume while out on LOA. Licensed Nurses were educated on the above, to include documentation of the discussion in the medical record, upon Resident's Leave of Absence. ED/DON/ Assistant Director of Nursing (ADON) educated current licensed nursing staff on 08/18/2021 that residents will be assessed upon return from LOA for an acute change in condition. Resident's physician will be immediately notified of an acute change in condition, as a result of the nursing assessment, for further orders. Staff members not educated by 8/20/2021 will be educated upon the next scheduled shift. The Executive Director will be responsible for tracking staff that have completed the education. On 8/20/21 the Executive Director provided education to the Assistant Director of Nursing that she would be responsible for training the staff that are not educated by 8/20/21. The facility Social Worker will be responsible for notifying staff and placing this information in the electronic medical record, hard paper chart under the Demographics tab, as well as in the LOA sign out/sign in book for new admissions with a legal guardian after 8/18/21. The facility Social Worker was notified of this responsibility on 08/18/2021. The staff were provided education on 8/20/21 by Executive Director to look to at the medical record/ resident sign out notebook to validate if the residents have a court appointed guardian before allowing them to leave the facility. On 8-20-21, an ad-hoc Quality Assurance Performance Improvement Committee meeting was held with the Executive Director, Medical Director, DON/ADON, and Social Services Director to review and adopt the plan of action to abate the Immediate jeopardy. The facility alleged immediate jeopardy removal effective date 8/21/21. The facility's credible allegation for immediate jeopardy removal with the correction date 8/21/21 was validated on 8/27/21. The Administrator revealed an initial in-service was provided to her by the Regional Vice President of Operations via phone on 8/18/21 to ensure LG's were called before the resident could leave and that training was provided to nursing staff, Department Heads, Business Management Office, and Receptionist. Review of the education provided by the interim DON for staff included the following information: Residents with an appointed Legal Guardian (LG) are unable to make decisions for themselves regarding leaves of absence and the LG will be notified; approval and/or disapproval will be witnessed by 2 staff and documented in their medical record; special diet education will be provided upon leave completed on 8/20/21. The interim DON confirmed her, and the DON provided training to staff that was completed on 8/20/21. The training was related to the facility's process for approval of leave for a resident deemed incompetent with an appointed LG. An interview with the SW revealed she was aware it was her responsibility to notify and maintain residents with an appointed LG with a permanent note in their hard chart and in the sign in/out logbook triggering facility staff to contact the LG before the resident could leave the facility. Interviews conducted with nurses revealed they were responsible for checking the residents medical record for guardianship and provide notification to the LG before a resident could leave and to provided education related to a resident's diet and upon return assess for a change of condition and notify the physician if concerns were noted and to document all the above. Interviews with Nursing staff, Department Heads, Business Management Office staff, and Receptionist revealed they were able to define what it meant for resident to be deemed incompetent and the role of their LG and knew the facility's process for when a resident with an appointed LG wanted to leave the facility. The sign in/out logbook was reviewed and found no other resident with an appointed LG were signed out during 08/2021. A Quality Assurance and Performance Improvement (QAPI) dated 8/20/21 identified a resident with court appointed LG left facility without approval. The goal was to review residents currently residing with LG. The QAPI signatures included the Administrator, the interim DON, and the Medical Director. The medical records of the 9 residents with an appointed LG were reviewed and revealed the following: - Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Diet orders were in place with instructions for texture and consistency of fluids. - The sign in/out logbook kept at the reception desk identified the 9 residents using a permanent note with directions to check with their LG before leaving the building with anyone and provided the LG's contact information. - The hard chart for the 9 residents with an appointed LG contained a permanent note with directions to check with their LG before leaving the building with anyone and provided the LG's contact information.

Based on record review and interviews with the Legal Guardian (LG), resident, staff, and the Nurse Practitioner (NP), the administration failed to provide oversight and leadership to Department Heads (DH) and direct care staff to effectively communicate which residents were assigned legal guardianship and ensure a guardian's directive to only leave the facility with authorized persons was followed for 1 of 3 resident (Resident#1) reviewed for accidents. Immediate Jeopardy (IJ) began on 08/13/21 when the facility's administration failed to effectively communicate to DH and direct care staff which residents were assigned a LG and failed to communicate the LG's directives that a resident could not leave the facility with an unauthorized person. The failure of administration to effectively communicate LG directives placed Resident #1 and other residents at risk for harm or serious injury. Immediate Jeopardy was removed on 9/4/21 when the facility provided and implemented an acceptable credible allegation for removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not IJ) to complete education and ensure monitoring systems put into place were effective. The findings included: The citation was crossed referenced with F 551: Based on record review and interviews with the Legal Guardian (LG), resident, staff, and the Nurse Practitioner (NP), the facility failed to follow instructions from the LG and allowed Resident #1 to leave the facility with an unauthorized person. Resident #1 was later diagnosed with aspiration pneumonia. This situation affected 1 of 3 residents reviewed for accidents. The Administrator was informed of immediate jeopardy on 9/2/21 at 6:48 PM. The facility provided the following acceptable IJ removal plan with the correction date of 9/4/21. A brief summary of the allegation: The Social Services Director spoke with the guardian of Resident #1 and was informed that he was not allowed to leave the facility on 8/14/2021 to attend a festival. However, the Social Service Director did communicate to some but not all of the department heads during stand down. The Director of Nursing was unaware of the directive from the guardian and allowed the resident to sign out of the facility and go to the festival on 8/14/2021. Other direct care staff were not aware of the guardian's directives because it had not been communicated to them by any department head. Identify those recipients who have suffered, or likely to suffer, a serious adverse outcome as a result of the non-compliance. Executive Director (ED)/Social Services (SS) Director identified 9 residents with legal guardians on 8-18-21 as those residents who are unable to make decisions for themselves regarding leaves of absence from the center. Current residents have been reviewed by the ED/SS Director on 8-18-21 to ensure that they have not been out on leave of absence without permission from their legal guardians. Also, current residents who have been out on Leave of Absence (LOA) in the past 5 days (since 8-14-21) were assessed by the Director of Nursing (DON)/Assistant Director of Nursing (ADON) on 8-18-21 to ensure no changes in condition, as a result. Residents on specialized diets were reviewed by the ED/DON/ADON on 8-18-21 to ensure consumption of approved diet, as ordered by the MD while out on LOA in the past 5 days (since 8-14-21). There were no additional changes in condition noted for other identified current residents, who had gone out on LOA from 8-14-21 through 8-18-21, requiring immediate notification to the MD by the Licensed Nurse for additional orders. All 9 residents with a guardian have been validated that the current plan of care is accurate. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. The Regional Vice President of Operations (RVPO) educated the ED on 09/02/2021 in regards to effective communication pertaining to the administrative staff being informed during the facility's daily stand up and stand down meetings on residents with guardians and the directives given by that guardian concerning their resident. If a department head is not in attendance an email and phone call will be made to that department head by the ED to inform them of the most recent changes to the resident's plan of care during morning meeting. The department head will notify their staff of residents with guardians and inform them of the guardian's directive concerning the resident. The DON or designee will use on-shift (internal staffing communication platform) to send a notification to direct care staff which includes agency staff upon knowledge of the change in plan of care. On the weekend the Customer Service Liaison (CSL) who is a current department head will ensure that staff are aware of the residents with guardians and directives given by the guardians concerning their residents. Any concerns identified the CSL/Department Head will notify the ED immediately. The ED will educate the administrative staff on 09/03/2021 in regards to effective communication pertaining to the administrative staff being informed during the facility's daily stand up and stand down meetings on residents with guardians and the directives given by the guardian concerning their resident. If a department head is not in attendance an email and phone call will be made to that department head by the ED to inform them of the most recent changes to the resident's plan of care during morning meeting. The department head will notify their staff of residents with guardians and inform them of the guardian's directive concerning the resident. The DON or designee will use on-shift (internal staffing communication platform) to send a notification to direct care staff which includes agency staff upon knowledge of the change in plan of care. On the weekend the Customer Service Liaison (CSL) who is a current department head will ensure that staff are aware of the residents with guardians and directives given by the guardians concerning their residents. Any concerns identified the CSL/Department Head will notify the ED immediately. The facility alleged IJ removal effective date 9/4/21. The facility's credible allegation for IJ removal was validated on 9/7/21. Review of the education completed revealed the ED received training on a system put into place to identify residents with a LG and their directives. The ED explained her role was to ensure DH staff were aware of residents with a LG and information pertaining to directives were delivered upon receipt to DH staff during stand up and stand down meetings and/or a follow up email and phone call to ensure all DH staff received the most up to date information. Interviews with DH staff revealed they were able to explain how they were kept up to date with directives and their role in informing the appropriate staff to ensure direct care and agency staff received the most current up to date information pertaining to a resident ' s specific directives put in place by their LG. Interviews were conducted with newly hired and direct care staff to confirm they were aware where and how to locate legal guardianship information for residents residing at the facility. During an interview on 9/7/21 at 2:53 PM the ED revealed she received education from the Regional Vice President of Operations pertaining to the process for communicating with DH staff and to discuss residents with changes to their directive during stand up and stand down meetings. If a DH was not present it was also the ED's responsibility to notify them via email and phone call to ensure the most current directive information was received. The ED explained it was the responsibility of each DH to notify their staff and the Director of Nursing would be responsible for the nursing and/or direct care staff including agency staff using an on-shift system to send a text requesting staff see their DH. It was then the DH's responsibility to inform their staff of changes or new directives put in place by a resident's LG. The ED also revealed their ad-hoc meeting confirmed the root cause of LG directives not being followed was a lack of communication between DH, nursing, and agency staff.